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Author of Prize Essay on Extracting Teeth, etc. : FeBotc of the -V. H. Medical 
Corresponding Member of the Odontographic Society of Pennsylrania 
Honorary Member of the Xev Tort Dental Society : Honorary 
Member of the Merrimae Valley Dental Society; Hon- 
orary Member of the Maine Dental Society. 



18 68, 


Entered according to Act of Congress, in the year 1868, 


In the Clerk's Office of the District Court of the United States for the 
Eastern District of Pennsylvania. 





























The operation of extracting teeth being at 
best a painful cne, and one to which almost 
every individual of the more than thirty mil- 
lions of inhabitants of this country, as well as a 
large share of the remaining one thousand mil- 
lions of the human race are necessarily sub- 
jected, and millions of them many times each ; 
the interests, the comfort of humanity demand 
that those who perform the operation should be 
so instructed as to be able to do it in the most 
skilful manner. And, strange as it may seem, 
the author of this is not aware that there is any 
work, in any language, devoted exclusively to 
that subject. All, so far as he knows, that has 


been written on the subject, being comprised in 
a few minor articles in the dental journals, and 
an occasional chapter in treatises on practical 
dentistry — works but little likely to fall into 
the hands of the great mass of those whose duty 
requires them to perform this operation. 

Having for a long time felt the necessity of 
such a work, by having seen the evil conse- 
quences to patients for want of skill on the 
part of the operator: and having often expe- 
rienced, in his early career, the anxiety and 
trepidation of being obliged to perform opera- 
tions in the principles of which he was not fully 
instructed, the author, after an experience of 
many years, has, in this little manual, under- 
taken to set forth, as clearly as possible, all the 
principles involved in the operation ; as well as 
the necessary manipulations required ; founded 
on the anatomy of the parts concerned ; the 
proper construction of the appropriate instru- 


merits to be used ; and the best means of re- 
trieving the accidents liable to occur in per- 
forming the operation. 

If in this undertaking it shall prove that 
he has contributed something toward the relief 
of the pains and sufferings of humanity, he will 
congratulate himself with the belief that he has 
not lived and labored in vain. 

Abr. Robertson. 





The operation of extracting decayed and painful 
teeth, has been performed, in some manner, from 
very remote antiquity. At first, and for many ages, 
for want of the necessary anatomical knowledge, 
and probably for various other reasons, it was per- 
formed with very unsuitable instruments and in the 
roughest and most barbarous maimer. Justice also 
compels us to admit that but comparatively slight 
improvements had been made, either in the instru- 
ments used in the operation or in the manner of 
using them, till after the lapse of the first quarter of 
the present century, although great advances had 
been made in the knowledge of anatomy previous to 
that time. And we are compelled, in honesty and 



in sorrow, further to say, that very many still, who 
extract teeth, have made but very little advance on 
the most primitive instruments or the application of 
them, although the anatomy of the human system 
has now been studied, almost to the counting of the 
hairs and fibres of the whole organization. This 
may probably be accounted for from the fact that 
anatomy has not been studied with especial refer- 
ence to this particular object. But another and a 
stronger reason is, that in times past, and not very 
remote, extracting teeth, with bleeding, cupping, 
and leeching, and, indeed, most other surgical opera- 
tions, was consigned to the care of barbers, as not 
worthy the attention of learned physicians. From 
this degradation it has not yet altogether recovered. 
But, happily for humanity, it is not now generally 
considered beneath the dignity of the wisest and the 
best, to do anything that will relieve suffering mortals 
from the severest torments " to which flesh is heir." 

But, as what has been done badly, or is badly 
done, has but little to do with what should be done 
well, or is well done, we will spend no time in de- 
scribing either those primitive instruments or the 
primitive manner of using them. The curious can 
find them described in other volumes. 

But, as this operation is more frequently performed 
than any, or all other surgical operations combined, 


almost every individual in this country of mature 
age, having been obliged to submit to it more or less 
repeatedly, and, as it is usually accompanied with 
more dread than any other operation of equal impor- 
tance, and as it is always (unless anaesthetics are used) 
a painful operation ; and when unskilfully performed, 
a very painful one, and sometimes even a dangerous 
one, it is "therefore important that it should always 
be done in the most careful and skilful manner. 
What we now propose to do, is to describe and illus- 
trate the instruments best adapted to the perfect 
accomplishment of the object under consideration, — 
the entire removal of every tooth and root of a tooth 
that requires extraction, with the least exertion, 
with the least amount of force by the operator, 
with the least possible injury to the surrounding 
parts, and consequently with the least amount of 
present pain and after-suffering to the patient, and 
the most appropriate methods of applying and using 
such instruments to effect such results. 

But, before attempting to use or to apply any in- 
struments for the extraction of the teeth, preliminary 
knowledge is indispensably requisite ; to wit : a dis- 
tinct and definite knowledge of the anatomy of the 
teeth, in at least so far as their external forms and 
articulations are concerned, and of the jaws, their 
articulations and appendages. A knowledge, too, of 


the pathology of the teeth is no less necessary and 
indispensable rightly to qualify one to perform the 
duties of this branch of surgery. 

A knowledge of anatomy can best be acquired in 
the dissecting-room ; and perfectly only there. The 
author would therefore most urgently recommend to 
every one who intends devoting himself to the allevia- 
tion of the pains of his fellow-beings by extracting 
their teeth, there to seek this knowledge ; for with- 
out it, sad mistakes and injuries are liable to be com- 
mitted wiih the very best of instruments. 

This knowledge is necessary, not only to enable 
one to know when and how to operate, and to guard 
against the occurrence of accidents and injuries, but 
if, as is sometimes unavoidably the case in the hands 
of the most skilful, — an accident does happen, it is 
still more necessary to enable him to make the best 
possible amends. For a knowledge of the anatomy 
of the parts involved, is the foundation of all surgery, 
and the only thing that enables one knowingly, and 
therefore the most effectually, to repair such acci- 

Since then a knowledge of the anatomy of the 
teeth is a sine qua non in even learning to extract 
them, and as all may not be able to study it in the 
dissecting-room, we will devote a preliminary chapter 
to that subject. 



Sec. 1. The jaws are two, upper and lower (or 
superior and inferior). The upper jaw, entire, is 
composed of the two superior maxillary bones which 
unite at the medial line of the face. They each con- 
sist of what is called a body and four processes — the 
nasal, malar, alveolar, and palate processes — and give 
form to the anterior middle portion of the face, and 
help to form the nose, the orbit, the cheek, and the 
palate. The body of the bone is of an irregular 
triangular form. Its interior is hollowed into a large 
triangular, but in size and form irregular, cavity 
called the antrum maxillare, or antrum highmoria- 
num ; on the internal surface of which are numerous 
small grooves, for the lodgment of the superior max- 
illary nerve and its branches ; and in its floor are 
sometimes found several conical processes, corres- 
ponding to the roots of the molar teeth, which occa- 
sionally penetrate this cavity. This bone has four 
faces or sides ; the external or facial, which is the 



anterior part of the bone, the interior or nasal, the 
snperior or orbital, and the posterior or zygomatic. 

Fig. 1. 

Fig. 1. a, The body of the left superior maxilla ; b, Canine fossa; c, 
Infra-orbital foramen ; d, Incisive fossa; e, Harmonial suture of the two 
bones;/, Nasal spine; «-, Semilunar notch of anterior nares ; k, Nasal 
process ; i, Articulation with lachrymal bone ; j, Malar process ; /:, Tu- 
berosity of superior maxilla; /, Cavity of the antrum ; m, Lachrymal tu- 
bercle ; n, Orbital process. 

I^ear the centre of the irregular concave facial 
surface is a deep depression, called the canine fossa, 
which gives attachment to certain muscles of the 
mouth and nose, and immediately above this fossa is 
the infraorbital foramen, which transmits what re- 
mains of the superior maxillary nerve, after having 
supplied branches to all the teeth — a branch to each 
root — in the upper jaw. There are other fossse or 
corrugations of this face of the bone, which give at- 


tachment to other muscles ; but, as they are not im- 
portant to our present purpose, we shall not describe 

The nasal surface forms a portion of the opening 
of the nose, and articulates with the lachrymal, eth- 
moid, and palate bones. 

The superior or orbital surface is thin and triangu- 
lar, and forms the floor of the orbit and roof of the 
antrum maxillare. 

The posterior or zygomatic surface is bounded an- 
teriorly by the malar process, and interiorly by a 
rough rounded border, called the tuberosity, which 
is pierced by several small foramina, which give pas- 
sage to the posterior dental nerves and the superior 
dental artery. The lower part of this tuberosity 
articulates by a rough rounded surface with the 
palate bone. 

The four processes of this bone, as already named, 
are the nasal, malar, palate, and alveolar. 

The nasal process forms the lateral boundary of 
the nose, and articulates with the nasal and frontal 

The malar process is large and irregular, and is at 
the angle of separation between the facial and zygo- 
matic surfaces, and articulates, by a large triangular 
surface, with the malar bone. 

The palate process projects horizontally inward 



from the inner surface of the body of the bone. It 
is thick and strong, and is concave, both above and 
below, and forms the floor of the nares and a part 
of the roof of the palate. 

The alveolar process forms the lower margin of 
the bone. Its exterior is dense and firm, its interior 
cellular. It contains in its whole length, a series of 
cells or cavities, into which the teeth are articulated, 
corresponding in number, size, form, and depth, to 
the number, size, form and length of the roots of 
the teeth in the jaw. 

Fig. 2. 

This process is much thicker where it arises from 
the body of the bone than at its free margins, at the 
necks of the teeth. Here it is thin ; sometimes very 
thin and sharp. The septa between the cells, con- 
taining the roots of individual teeth, and between 
the different teeth, are thicker or thinner according 


as the roots are divergent or close, or as the teeth 
are near or far apart. 

In the bottom of each of these alveolar cells is a 
small perforation, or foramen, for the transmission 
of a nerve and artery to, and returning vein from, 
the root of a tooth contained in it. 

The lower jaw is the largest bone of the face ; and 
although it consists of two distinct symmetrical 
halves in the foetus, is but one bone in the adult, 
united by a ridge at the centre, or that part which 
forms the chin, which is called the symphysis. It is 
of a semicircular, or more nearly, of a horseshoe 
shape ; extends from the chin to the base of the 
skull, where it articulates with the glenoid fossa? of 
the temporal bone. It gives form to the lower part 
of the face. It is divided into a body and rami. The 
body is the horizontal portion, and on both its ex- 
ternal and internal surfaces are various protuberances 
or processes, and indentations or fossae, which afford 
attachments to the muscles of the lips and tongue ; 
but as, in extracting the teeth, we have but little to 
do with any muscles except those which close the 
jaws, we shall not stop now to describe them. 

About the middle of the bone, and just below the 

roots of the canine teeth, are the mental — sometimes 

called the anterior mental — foramina, which afford 

exit to the inferior dental nerve and artery, after 


each, having supplied a branch to each root of a tooth 
contained in the jaw. The upper edge of the jaw is 

Fig. 3. 

Fig. 3. Tho inferior maxilla ; a, Body of the bone ; b, Mental foramen ; 
c, The symphysis; d d, Alveolar processes; e, Ramus of the lower jaw; 
/, Its angle ; gg, Coronoid processes ; h h, Sigmoid notch ; ii, Condyloid 
processes ; jj, Neck of the condyles ; k, Inferior dental foramen ; /, Mylo- 
hyoid ridge. 

surmounted by the alveolar processes and cells, cor- 
responding, like those in the upper jaw, in number, 
size, form, and depth, to the number, size, form and 
length of the roots of the teeth which they contain 
and support. These processes are wanting, mostly, 
in foetal life and early infancy ; and in old age, or at 


an earlier period, with the loss of the teeth, are 
gradually wasted or absorbed away ; coming with 
the teeth and departing with them. 

Fig. 4. 

The anterior alveolar processes are thinner and 
higher than the posterior ; the roots of the wisdom 
teeth being almost entirely imbedded in the body of 
the bone, or having at most a very short and thick 
process ; a circumstance of great practical importance, 
as- we shall see, when treating of the extraction of 
the lower wisdom teeth. 

The ramus of the jaw is a strong, oblong-shaped 
process, rising from the posterior portion of each 
side of the body, forming an angle more or less ob- 
tuse, according to the age of the individual ; in foetal 
and infantile life being very obtuse, or almost hori- 
zontal with the body of the bone. In youth, and 


till mature manhood, it slowly advances toward a 
perpendicular position, or right angle. After the 

Fig. 5. 

loss of the teeth, in old age, it is said again to de- 
cline. The upper portion of the ramus is divided 
into two processes, by a broad fissure, called the sig- 
moid notch. (See Fig. 3.) 

These processes are called the coronoid process, and 
the condyle of the lower jaw. The anterior, or coro- 
noid process, is broad at its base, rather thin, of a 
triangular shape, and affords attachment to the tern- 


poral muscle. The posterior, or condyle of the jaw, 
is flattened from before backward, and is smooth on 
its top to form its hinge-like articulation. 

Eear the centre of the internal surface of the 
ramus is the inferior dental foramen, through which 
the inferior dental artery and nerve enter the jaw, 
and are transmitted through the body of the bone 
below the alveolar cells (each of which, like those in 
the upper jaw, is perforated by a minute foramen, 
for the transmission of a branch of each to its con- 
tained root of a tooth, and for the egress of the re- 
current vein) to the mental foramen, where they pass 
out to be distributed on the chin. The posterior 
junction of the ramus with the body of the bone 
forms a rough tuberosity, called the angle of the 

Sec. 2. The muscles that are chiefly concerned in 
the extraction of the teeth, and more particularly in 
the accidents that may sometimes occur in connec- 
tion with that operation, and therefore require our 
present attention, are the temporal, the masseter, 
and the external and internal pterygoid. These are 
the elevators of the lower jaw, and also give it its 
forward, backward, and lateral motions. 

The upper jaw has no independent motion. It 
only moves with the motions of the whole head. 



The masseter is a short, thick, quadrilateral-shaped 
muscle. It arises from the tuberosity of the superior 

Fig. 6. 

Fig. 6. g, Zygomaticus minor ; h, Zygomaticus major ; i, Masseter 
muscle ; r, Deep-seated portion of masseter. 

maxillary bone, the lower margin of the malar bone, 
and from the zygoma, and is inserted into the ramus 
and angle of the lower jaw. 

The temporal is a broad, radiating muscle, occupy- 
ing a large part of the side of the head. It arises 
from the whole length of the temporal ridge, from 
the temporal fascia, and from the entire surface of 
the temporal fossa. Its fibres converge to a narrow, 



but strong tendon, which is inserted into the apex of 
the coronoid process, and from some distance down 
its inner surface. 

Fig. 7. 

Fig. 7. a, Side view of the temporal muscle, exposed by the removal 
of the temporal fascia ; b, External lateral ligament of the lower jaw ; 
c, Insertion of temporal muscle into coronoid process of lower jaw. 

The internal pterygoid (Fig. 8) is a thick quad- 
rangular muscle. It arises from the pterygoid fossa, 
and descending obliquely backward, is inserted into 
the ramus and angle of the lower jaw. From its 
resemblance to the masseter, in appearance and di- 
rection, it has sometimes been called the internal 


The external pterygoid is a short, thick, trian- 
gular muscle, being broader at its origin than at its 
insertion, (a, b, Fig. 8.) It arises from the pterygoid 

Fig. 8. 

Fig. 8. a and b, Superior and inferior portions of the pterygoideus ex- 
ternus ; e, Pterygoideus internus ; d, Root of zygomatic process ; e, Con- 

The ramus is cut away, to show the internal pterygoid muscle. 

process, pterygoid plate, and the tuberosity of the 
palate bone. It passes backward, and is inserted 


into the neck of the lower jaw and its capsular liga- 

The office of the pterygoid muscles, when acting 
separately, is to give the lateral, or grinding, motion 
to the jaw. When acting together, they thrust the 
jaw forward, and close the mouth. 

Sec. 3. Anatomy of the Teeth. — Man, in common 
with most other animals, is supplied with two com- 
plete and distinct sets of teeth, — a temporary and 
a permanent set. 

In mankind, the temporary set, called also decidu- 
ous or milk teeth, consists of twenty teeth, ten in 
each jaw. They are of the sizes, forms and struc- 
ture suited to the size of the jaws, and to the neces- 
sities of infancy and childhood. AVhcn hy the ab- 
sorption of their roots they are loosened and drop 
out, or are removed, their places are supplied by 
another, a larger and a stronger set, suited to the 
increased size of the jaws and to the wants of ma- 
ture life. 

The temporary set is divided into three classes : 
incisors, of which there are four in each jaw; canine 
teeth, or cuspidati, two in each jaw ; and molars, or 
grinding teeth, four in each jaw. 

The roots of the temporary molars are generally 
broader and thinner, and more divergent, according 


to their size, than the corresponding permanent 
ones ; and as this is the only material difference 
between them, or any other of the corresponding 
classes of the two sets, except the much smaller size 
of the temporary, a particular description of their 
forms is here unnecessary. 

The permanent set consists of thirty-two teeth, 
sixteen in each jaw. They are divided into four 
classes, each having very distinct and definite forms ; 
to wit : four incisors, two canine or cuspidati, four 
bicuspidati or small molars, and six molars, in each 
jaw. The incisors, for convenience of description, 
are, from their positions, subdivided into right and 
left, central and lateral incisors. The bicuspidati, 
into first and second, or anterior and posterior, right 
and left; and the molars, into first, second, and third, 
right and left molars ; always reckoning from the 
front backward. The third molars are also called 
dentes sapientiae or wisdom teeth, from their coming 
later in life. They vary greatly in the time of their 
coming ; sometimes appearing as early as sixteen 
years of age, and sometimes not before thirty-five. 

The length, width and thickness of all the teeth, 
and the curvatures of the crowns of the incisors, 
vary materially in different individuals, according to 
the configurations of the persons to whom they be- 
long. Thus, tall, slender persons, usually have com- 


paratively long and narrow teeth, while short, thick- 
set persons have shorter, broader, and thicker teeth. 
Short thick-set persons too, usually have thicker 
bones and alveolar processes than those with more 
slender forms. Their teeth are generally more fimly 
set, and therefore, require more force to effect their 

The color of the teeth varies too, in different in- 
dividuals, from an almost pearly white, to a deep 
tinge of yellow, brown, or blue, closely corresponding 
with the complexion of the individual. Their color 
also varies with the age of the individual, from light 
in youth, to dark in age. 

Their density, strength and durability are also 
quite variable, cachectic and lymphatic persons 
mostly having thin, soft, frail teeth, while the robust 
and healthy have thicker, denser, stronger, and more 
durable ones. Their density varies, too, with the 
age of the person, being much more solid in age 
than in youth. 

Each tooth, for convenience of description, is di- 
vided into three parts : the crown, the neck, and the 
root or roots. The crowui extends from the edge of 
the cutting, or the grinding surface, as the case may 
be, to the gum ; Or is that part which is exposed to 
view, and is covered by the enamel. 

The neck is the slightly constricted portion next 



to the crown, and extends, when the parts are in a 
normal condition, from the edge of the gum to the 
edge of the alveolus, or perhaps more strictly, from 
the crown to the bifurcation in the molar teeth. 

The root, is that part of the tooth contained within 
the alveolar cell or socket, and articulates it with 
the jaw. 

Although the crowns of the same class of teeth 
vary very much in form and size, in different in- 
dividuals, a general outline of the description of any 
tooth belonging to a given class will be the same. 

The superior central incisors occupy the anterior 
central portion of the upper jaw ; one on each side 
of the mesial line of the face. Their crowns are of 
an oblong, quadrilateral form, averaging about five 

Fig. 9. 

lines in length by four in width ; and usually a little 
wider at their free, or cutting edges', than at the gum, 
or necks of the teeth. Their cutting edges are nearly 
straight across, though their corners, and especially 


their outer ones, • are sometimes slightly rounded. 
Their anterior, or labial surfaces, are always more or 
less convex, while their inner or posterior surfaces 
are correspondingly concave ; the interior surface 
forming the segment of a smaller circle than the 

The tooth is much thicker at the gum than at its 
edge, and presents an appearance as if it had been 
formed into a wedge, by cutting away the inner sur- 
face of the tooth, and then slightly bending it in- 
ward, with a regular curve from the neck to the edge. 
The roots of these teeth average about seven lines in 
length, and about three lines in diameter. They are 
irregularly conical in shape, tapering, somewhat un- 
evenly, to their points ; and the outer portion forming 
the segment of a rather larger circle than the inner. 

The lateral incisors are next in order to the cen- 
trals. Their crowns are usually a little shorter than 
those of the centrals, in the same mouth, and about 
three-fourths their width. Their corners are more 
rounded than those of the centrals, and especially 
their outer corners, which are generally considerably 
so. Their roots, though slightly shorter, are very 
nearly of the same length as the others, but are gen- 
erally considerably more flattened, or compressed, lat_ 
erally, than they. The outer portion, like the cen- 
trals, is larger than the inner. 



Next to the lateral incisors arfc the cuspidati or 
canine teeth ; one on each side. The crowns of these 
are abont the same length and width as the central 
incisors ; bnt they are thicker at their necks, from 
their outer to their inner surfaces, and stronger than 
the incisors, and instead of being like them broad 
and straight across their edges, they are tapered for 
abont half their length to a blunt spearlike-shaped 
point. They are also more convex on their labial 
surfaces, and but slightly, if at all, concave on their 
internal or lingual surfaces. From their greater 
thickness they stand a little more prominent than 

Fig. 10. 

the other teeth, forming approximations to corners 
in the dental arch. Their roots are both larger and 
longer than those of any of the other teeth, being 
most commonly a line or more longer than those of 
the central incisors. Their roots are also shaped dif- 
ferently from those of any of the other teeth, for they 


are not only larger at their neck, but they taper to 
more slender points. They are, though sometimes 
almost perfectly round, usually about once and a half 
as large in their antero-posterior diameter as in their 
approximal, with the appearance of having been com- 
pressed or flattened like the roots of the upper lateral 
and all the lower incisors. A transverse section of 
the root presents an ovoid form, though the outer or 
larger portion of the root would generally be a little 
larger, and the smaller or inner portion a little 
smaller in proportion, than a longitudinal section of 
an egg. The roots of these teeth are more frequently 
curved, in part, or all of their length, and more sub- 
ject to have short crooks in them, and are generally 
more closely and firmly articulated with the alveolus, 
and therefore require more force for their removal, 
than any other of the single-rooted teeth. 

All the incisors and cuspidati of both jaws, the 
second or posterior bicuspidati of the upper jaw, and 
all of the bicuspidati in the lower jaw, have each 
uniformly but one root.* 

The upper bicuspidati come next in order. 

Their crowns are a little shorter than the preced- 

* Since writing the above, Dr. Kandall, of Farmington, Presi- 
dent of the Maine Dental Society, has shown me a pair of upper bi- 
cuspidati, extracted by him, having two well-defined roots each, — 
the bifurcation extending to their necks. 



ing, and are very nearly an ovoid shape, but some- 
what compressed on their approximal sides, — the 

Fig. 11. 

larger end representing the grinding surface of the 
tooth, which is furrowed in the direction of the arch 
of the teeth by a broad triangular groove, thus leav- 
ing two — an outer and an inner — rather blunt tuber- 
cles or cusps, and the smaller end of the egg trun- 
cated to represent its union with the neck of the 

The first or anterior bicuspidatus on each side, 
most commonly, but not uniformly, has two roots, 

Fig. 12. 


an external and an internal. They are small and 
round ; sometimes regularly and increasingly diver- 
gent from their bifurcation to their points. Some- 
times they are considerably divergent for a half or 



two-thirds of their length, and then convergent till 
their points nearly, or even quite, come in contact 
with each other. Sometimes they take a course 
quite close and parallel to each other, as if they had 
been originally hut one flattened root, simply split 
in two. At other times they are found having but 
one root, very much flattened on its approximal 
sides, and grooved so as to show the rudiments of 
two roots. 

The second or posterior bicuspidati, as already re- 
marked, have uniformly but one root each, which 
is always compressed or flattened and grooved on its 
approximal sides. Their crowns are entirely similar 
to those of the anterior. The roots of all the bicus- 
pidati are of about the same length as are those of 
the incisors. 

Fig. 13. 

The upper molar teeth, three on each side, are the 
last in the order, and the largest of them all. Of 
these, the first or anterior is a little the largest, and 
the third or wisdom tooth is considerably the smallest. 


The crowns of these teeth are nearly cubical in 
shape, with their corners all rounded. In size each 
of their surfaces or faces is about equal to or a little 
larger than the face of the central incisor belonging 
to the same set. Their grinding surfaces are of 
course broad, and they are furrowed or cut by several 
triangular grooves leaving at least four or more tu- 
bercles or cusps. 

They have ordinarily each three roots. Two ex- 
ternal or buccal, and one internal or palatal. The 
external roots are an anterior and a posterior. Of 
these two, the anterior is larger than the posterior, 
being indeed about twice its size ; it is broad and flat, 
being compressed from before backward, and stands 
out more prominently in the arch than its fellow. 
The two stand nearly perpendicular to the outside of 
the crown, but usually diverge more or less from 
each other. The internal root is generally the long- 
est of the three. Its size is about the same as that 
of the anterior external root, but instead of being 
flattened like that, it is round or nearly so. It gen- 
erally diverges considerably from the perpendicular 
of the crown toward the palate, but after diverging 
for about two-thirds of its length, the remaining por- 
tion most commonly converges toward the points of 
the other roots. Sometimes, and indeed not unfre- 
quently, this and one of the other roots are united 



for nearly or quite their entire length, into one hroad 
flat root. This union is much more frequent " with 
the anterior than with the posterior root. Sometimes, 
too, all three of these roots are combined into one 
large irregular root, which is simply grooved so as to 
show the rudiments of the three roots. This is much 
the most common, indeed, quite common, in relation 
to the third molar or wisdom teeth. 

The upper wisdom teeth too are perhaps more fre- 
quently found irregular in relation to the line of the 
arch of the jaw than any other class. 

"When malposition of these occur, they are gener- 
ally found with their multi-cuspidated or grinding 
surfaces looking toward the cheek. So circumstanced 
the roots of teeth are usually more or less hook-shaped, 
as if the crown of the tooth had been seized while 
standing in its proper position and forcibly bent out- 

Fig. 14. 

The crowns of the lower incisors are of about the 
same length as are those of the upper, but much 



narrower, these being but about two and a half lines 
in width. They are a little broader at their cutting 
edges than at their necks. The centrals are usually 
a very little narrower than the laterals, while in the 
upper jaw the reverse of this always obtains : the cen- 
trals there being much broader than the laterals. 
The roots of the centrals are a little shorter than 
their laterals. The roots of all the lower incisors are 
very much compressed or flattened on their approxi- 
mal sides. They are very nearly of the same length 
as those of the corresponding teeth of the upper jaw. 
The lower canine teeth, or cuspidati, are shaped 

Fig. 15. 

very similarly to the upper, except that they are 
smaller and rather more pointed, and their roots are 
more compressed or flattened. 

The crowns of the low T er bicuspidati are of about 
the same length, but a little more slender than the 
upper. In form, otherwise, they are very nearly 



the same as those, except that the inner cusp of 
these is usually smaller, especially that of the first or 
anterior one, which frequently presents only the rudi- 
ment of an inner cusp. 

The inner cusps of both the upper and lower bi- 
cuspidati are always smaller than the outer? 

The roots of these teeth are also a little more com- 
pressed, and a little smaller than those of the corre- 
sponding upper ones. But as has already been re- 
marked, these teeth have invariably but one root 

The crowns of the lower molars so nearly resemble 
the upper, they require no separate description. 

They have each usually two roots: an anterior 
and a posterior. They are broad and flat, and thin- 
ner in their central portions than at their edges. 

The anterior root is generally a little larger and 
a little longer than the posterior. They bifurcate 
just at the edge of the alveolar process ; and at that 



point usually diverge more or less extensively to 
their extremities ; though they sometimes diverge 
only for a portion of their length and then converge 
till their points nearly or quite meet ; thus inclosiDg 

that part of the alveolus which forms the septum be- 
tween their sockets, which must be brought away on 
removing the tooth — a circumstance that often 
greatly complicates the operation of extraction, and 
always renders much more force necessary for that 
operation. Sometimes they diverge but little — the 
roots being parallel to each other and in almost com- 
plete apposition. Occasionally, too, each of these 
roots are divided in their centres, for a part or all of 
their length, making four distinct roots. This, how- 
ever, is of no practical importance, in so far, at least, 
as the operation for their removal is concerned. The 
lower wisdom teeth are more frequently irregular in 
the number of their roots than any others. 

The lower wisdom teeth have also another peculi- 


arity, which to some extent, at least so far as my 
observation has extended, is unvarying, and which 
is of very great practical importance, as it renders 
an entirely different mode of procedure and different 
instruments necessary for their ready removal ; 

Fig. 18. 

which I shall discuss more fully when treating of 
the extraction of this class of teeth, which in a 
description of the anatomy of the teeth must not he 
omitted. This peculiarity consists in the fact that 
the roots of these teeth are always more or less 
curved, sometimes almost hook-shaped, and the points 
of their roots or foramina — the point of every root 
of every tooth is pierced by a minute foramen, which 
affords passage for a branch of nerve and artery which 
supply nutriment and vitality to its crown — pointing 
or looking toward the angle of the jaw. 

Sometimes the roots of any or all of the lower 
molar teeth — and sometimes too, but more rarely, 
those of the upper molars — are found terminating in 
small hooks, as seen in the cut. 


The roots of the wisdom teeth are shorter than 
those of any other class. 

Fig. 10. 

The teeth are held in the jaws by a kind of artic- 
ulation peculiar to themselves, called a gomphosis 
articulation, or like that of a nail driven into a board 
or other substance. So it is denominated, and de- 
scribed, by anatomists; but in other words, and more 
exactly and more plainly, each root of every tooth 
lias a cell in the alveolar process, corresponding in 
depth and form to its form and length. These cells, 
or sockets, are enough larger than the contained roots 
of the teeth, to admit of their being lined by a dense, 
strong membrane, called the periosteum ; which is 
also reflected upon the root. This, with their rough- 
ness, their crooks, and their irregularity of form, and 


their divergencies and their convergencies, holds 
them very firmly in their places ; so that, when they 
are healthy and intact in all their parts, it requires a 
considerable force to remove or displace them. 



Sec. 1. Toothache proper — (there is scarcely more 
propriety in calling all painful affections of the teeth, 
toothache, than there would he in calling all pains 
in the head, headache) — is usually the result of either 
caries of the teeth, or of the absorption of the gums 
and alveolar processes, or of mechanical causes or 

Caries of the teeth is the effect of various causes : 
such as, deleterious substances coming in contact 
with, and acting chemically upon them ; hereditary 
malformations and imperfections in their organiza- 
tion and structure ; and from insufficient supply of 
the proper materials of which they are composed, oc- 
casioned by want of proper aliments, or an inability 
to assimilate them, by reason of sickness or other 
causes, while the teeth are in the process of forma- 
tion within the gums and alveolar processes. Me- 
chanical violence, too, may be an indirect cause of 
caries of the teeth. 


The agents that act chemically upon the teeth to 
produce caries, are acids. Many other substances 
may indirectly produce this effect, by deranging the 
general health, and thus changing some of the secre- 
tions, which in a normal state are either neutral or 
alkaline, to an acid reaction. This altered secretion 
coming in contact with the teeth decomposes and 
destroys them. Still the direct agent is an acid. 
All acids act upon the teeth, when in contact with 
them, with more or less vigor, according to their kind 
and strength ; hence persons addicted to eating 
lemons, or other strongly acid fruits, are very liable 
to suffer from caries of the teeth. 

Dyspeptics, who are troubled with great acidity of 
the stomach, and with frequent regurgitations of 
such fluid into the mouth, as is a very common 
occurrence in such cases, are almost always sufferers 
from this cause. Persons taking acids as medicines, 
without taking proper care to avoid their coming in 
contact with their teeth, or immediately to neutralize 
the acid, suffer in the same manner. 

The saliva in its normal state, including the saliva 
proper and the buccal mucus, is alkaline. The mucus 
is slightly acid, while the secretion of the glands — 
which is by far the most abundant secretion — is alka- 
line. One effect of a very large share, if not of most 
of the diseases to which humanity is subject, is to 


change the saliva from an alkaline to an acid reaction. 
Thus, during sicknesses of various kinds, the teeth are 
constantly hathed in acid, and therefore suffer greatly. 

As medicines are usually administered during sick- 
ness, and as the teeth are almost uniformly observed 
to suffer at such times, the almost universal impres- 
sion is, that all medicines injure the teeth ; whereas 
all medicines, so exhibited as to restore health — to 
restore the secretions, and especially of the mouth, 
from an unhealthy to a healthy condition, from an 
acid to an alkaline reaction, protect the teeth from 
decay, instead of injuring them. 

Even the stronger mineral acids, when so carelessly 
administered as to he allowed to come in contact with 
the teeth, and no care taken to neutralize them, 
though for the time they may severely injure the 
teeth, if they be not too long continued and if their 
effect be to restore the health, may even afford more 
protection than injury to them. But as such medi- 
cines, used without due care, greatly injure the teeth, 
great care should be taken to avoid their coming in 
contact with them, or they should be followed by 
such alkaline or antacid washes as will neutralize 
their effects. And in the topical use of some of the 
salts having acid bases, as nitrate of silver, by the 
greater affinity of its nitric acid for the lime of the 
tooth than for the silver, if allowed to come and to 


remain in contact with the teeth, will have the same 
decidedly injnrions effects ; it should therefore be 
administered with the same caution. 

So too, whenever the physician is called to the 
treatment of any case where the saliva is changed to 
an acid reaction, if he would do his patient all the 
good he can, he should prescribe antacid washes to 
be frequently used with a view to the protection of 
the teeth, and care should be used, too, to see that 
this* condition of the secretions is not overlooked. 

Imperfect organization of the teeth, from what- 
ever cause, subjects them to great liability to decay; 
for two reasons. First, such teeth are less capable 
of resisting the action of deleterious substances that 
may come in contact with them ; and secondly, and 
most especially, the enamel of such teeth does not 
perfectly cover and protect their dentine. They have 
imperfections or interstices, at the lines of union of 
the different parts of the enamel, where they approxi- 
mate and should unite, from the different points of 
deposit, affording ready lodgment for any free acids 
that may chance to be in the mouth, as well as for 
food to be forced into, by mastication, there to lie 
and ferment and become acid. 

Mechanical violence, as accidental fracture ; or 
chipping off small fragments of enamel, by biting 
very hard substances, as cracking nuts, and the like ; 



the use of the file, &c, has the same effect. They 
all remove more or less of the enamel, and also leave 
the surface roughened, so as to afford lodgment for 
foreign substances, and render them difficult to he 
kept clean. 

The habit of placing artificial teeth in the mouth, 
and sustaining them there by clasps, or bands, around 
other teeth, is also another great source of the decay 
of these organs ; and the broader these clasps are, and 
the more perfectly they are fitted to the teeth which 
they embrace, the more destructive they are ; for so 
much the greater and more perfect a lodgment do 
they afford for such foreign substances, and the more 
perfectly do they keep them in contact with the 
teeth. The bad effects, in these cases, are mostly 
chemical, and not mechanical. The use of clasps, 
therefore, is but rarely justifiable, and, fortunately, 
but very seldom necessary. 

Although caries is by far the most common cause 
of toothache, there are many other causes that pro- 
duce it, and caries itself produces several varieties of 
this most painful disorder. This, therefore, brings 
us to speak more particularly of the different 

Sec 2. Varieties of toothache and their causes. — For 
convenience and clearness of description, toothache 
may be divided into 


1. Toothache from exposure of the nerve (I use the 
word nerve in its common acceptation, implying by 
it the whole soft internal part of the tooth ; including 
nerve, artery, vein, and cellular substance, or as it is, 
by dentists, most commonly called the pulp of the 

2. From inflammation of the nerve without its 
direct exposure, resulting in the formation of pus in 
the dental canal, abscess, &c. 

3. From inflammation of its periosteum. 

4. From inflammation of its dentine. 

5. From sympathy or reflex irritation — neuralgic 

6. From exostosis. 

7. From accidents. 

1. Toothache from exposure of the nerve is probably 
the most common of all the varieties. This may be 
produced by the accidental fracture of the tooth, but 
is most commonly produced by caries. 

Caries may attack a tooth in any part of its ex- 
posed, or external surface ; but it does so most fre- 
quently, at the bottom of the grooves of the grinding, 
surfaces of the molars, in the interstices left by a de- 
fective union of the enamel there ; in the approximal 
surfaces of any or all of the teeth ; in the exterior or 
labial surfaces of the incisors, and of the cuspidati 


(and when in this surface most commonly j list at the 
edge of the gum), and often, but less frequently, on 
the buccal surfaces of the bicuspidati and molar teeth, 
and on the lingual surfaces of the incisors and cus- 

Toothache from exposure of the nerve generally 
occurs, except when caused by accident, where caries 
has progressed until but a very thin covering of 
dentine remains over the nerve, or if the caries have 
commenced, and has progressed with but a very 
small orifice through the enamel, until it has quite 
reached the nerve, undermining the enamel as it pro- 
gresses, and, as often happens without causing pain, 
when by picking the teeth or masticating food, or by 
biting some hard substance, this thin shell of enamel, 
or of dentine, as the case may be, is broken in, and 
the toothpick, or the fragment of the tooth, or por- 
tion of the food, is forced upon the nerve, producing 
a sudden attack of the most excruciating pain. This 
may be alleviated or entirely relieved, for the time, 
by the removal of the foreign substance, and the 
application of any of the stronger stimulants, as 
creasote, the essential oils, or chloroform ; but the 
pain will be liable to return whenever food, hot or 
cold fluids, cold air or other foreign substances, are 
suffered to come in contact with the nerve. In this 
state they sometimes remain for weeks, or even 


months, without giving much if any pain except from 
such extraneous causes ; when at length, from fre- 
quent irritations of this kind, inflammation will be 
induced, when a more continued, but still severe, 
pain will be likely to ensue. If left to its natural 
course, suppuration soon occurs and the nerve is thus 
destroyed, when, in many cases, all pain will cease 
and not again occur till the whole crown and even a 
large share of the root is wasted by decay. But this 
is by no means the uniform result ; for sometimes 
the inflammation of the nerve extends through the 
foramen to the periosteum. This occurs much most 
frequently in the lower jaw, where pus formed in the 
canal, or food, or the fluids of the mouth may be 
carried through the foramen by the force of gravita- 
tion, and thus produce inflammation about the point 
of the root. "When this state occurs, a less acute but 
a more steady and annoying character of pain ensues, 
and which is liable to be more acute at night while 
warm in bed, and in a horizontal position, than while 
up during the day. This may be accounted for by the 
warmth and the horizontal position favoring a greater 
determination of blood to the part than an erect po- 
sition. Occasionally too, from some remaining por- 
tion of the membranes, a troublesome, painful, fetid 
fungus will arise, sometimes filling the whole nerve- 
canal as well as the cavity caused by the decay, which 



will require the removal of the tooth. This kind of 
fungous growth may generally very readily he dis- 
tinguished from an exposed nerve hy its hright or 
red color, hy its heing far less sensitive, and hy its 
free bleeding on heing very slightly touched. Such 
bleeding will very much reduce the size of the tumor, 
and frequently entirely relieve the pain ; which may 
not again recur until the tumor is again formed and 
filled with blood, which however will most likely 
occur in a few days. 

In almost all cases of toothache from exposure of 
the nerve in the upper incisors and cuspidati, if the 
caries has not already so far destroyed the crowns of 
the teeth as to render the operation of filling imprac- 
ticable, a radical cure can be effected by early and 
efficient treatment ; and very many of these teeth 
can be restored to usefulness and health, by suitable 
treatment, even after they have been long neglected, 
and abscesses have been formed ; but such delay 
greatly complicates the difficulties and lessens the 
chances of restoration. A majority of the upper 
bicuspidati, many of the upper molars, and some of 
the lower teeth, may thus be saved. The success of 
the treatment, especially in the molars, will very 
much depend on the convenience, or the possibility, 
of getting at the part decayed, and through that 
to the nerve-canals ; without this possibility, all at- 


tempts at treatment must at best be very uncertain 
and most probably futile. 

In order to treat such, teeth successfully, the ex- 
posed nerves should be removed, either directly by 
the use of suitable instruments, or, where this is not 
practicable, by the use of caustics ; of which arsenious 
acid, moistened with creasote, is the most effectual 
and quickest in action ; from the twentieth to the 
sixteenth of a grain, or less, of which, applied on a 
very small pledget of lint or cotton, and left in con- 
tact, from six to twenty-four hours, being entirely 
sufficient, in most cases, to effect the object. Great 
care, however, should be taken in the use or arsenic 
for this purpose, to avoid letting it come in contact 
with the gums and other parts of the mouth, lest 
ulceration and sloughing be produced. Some very 
serious accidents have occurred from the incautious 
use of this article. 

After the nerve has been thus destroyed, the nerve- 
canals and the cavity of decay should be thoroughly 
cleansed from all diseased dentine, pus, and foreign 
substances ; or if the nerve has been destroyed, in 
the natural course of events, by suppuration, all such 
matters, and everything that might decompose and 
form either pus or gas, should be carefully cleansed 
away, and, if necessary, otherwise properly treated, 
and the roots and cavities carefully filled. 


The treatment of the upper teeth with a view to 
their preservation by destroying their nerves, is much 
more likely to be successful than of the lower, as the 
force of gravitation is liable to bring the articles used 
for the destruction of the nerves, as well as particles 
of food and the fluids of the mouth, during the time 
of the treatment, in contact with the periosteum at 
the point of the root, thus exciting a troublesome 
and sometimes an uncontrollable inflammation in 
that membrane. 

2. Toothache from inflammation of the nerve ivithout 
direct exposure. — This occurs when, from caries, the 
absorption of the gums and alveolar processes, attri- 
tion, or other causes, the nerve of the tooth has so 
far been deprived of its natural protection, that the 
passage over it of hot or cold fluids, or the contact 
of cold air, produces irritation of this delicate and 
extremely sensitive structure. A tooth may, and 
frequently does remain in this situation for a consid- 
erable length of time without being much, if any, 
troublesome, except while the cause of the irritation 
remains, as while taking a draught of cold water, 
a cup of hot coffee, or the like ; but at length, after 
repeated irritations of this kind, inflammation super- 
venes, and then the real trouble commences. 

When active inflammation exists in the nerve of 


a tooth, so circumstanced, a steady severe pain is ex- 
perienced ; and its intensity is owing, greatly, to the 
fact that inflammation in the soft parts always pro- 
duces swelling, and as the nerve — the pulp of the 
tooth — is confined in an unyielding canal of bone, it 
is subjected, by this swelling, to a severe pressure ; 
its only means of expansion or escape being through 
the minute foramen in the point of the root, which 
till suppuration has taken place is of no practical ef- 
fect, as it is altogether too small to admit of integu- 
ment or membranes being forced through it. 

Usually, within twenty-four hours of the com- 
mencement of severe pain, the tooth begins to feel 
sore, and a little longer than the rest, and perhaps a 
little loose. Sometimes the tooth is so sore, from 
the inflammation of the membrane about the point 
of its root, that but a slight touch upon it, with the 
finger, will make the patient start suddenly, or even 
cry out with the pain. 

At this stage, suppuration has commenced, and 
the pus is beginning to be forced through the fora- 
men of the root. The pressure of this matter pro- 
duces inflammation and swelling of the membranes 
at the bottom of its alveolar socket, and this raises 
the tooth slightly in its socket and accounts for its 
extreme sensitiveness to the touch ; and particularly, 


by its contact with its fellow opposite, on closing the 

If the case be not now relieved, the pns, by the 
pressure within, is forced through the foramen, and 
insinuated between the point of the root and its peri- 
osteum, forming a sac larger or smaller, from the 
size of a pin's head to that of a pea. During this 
stage the pain may dart along the course of the 
nerves, to any or all of the teeth on that side of the 
head, to the temple,.the ear, or the scalp ; or to any 
part where the branches of the fifth pair of nerves 
are distributed ; that being the nerve which supplies 
the teeth with branches. The pus still being con- 
fined in a bony cell — the alveolar cell — the pressure 
is great and the pain severe. But soon, the pus 
forces its way through the parietes of the alveolus. 
Then the face begins to swell, and the pain is less 
severe and of a different character — being of that 
throbbing character which indicates the formation 
of abscess, accompanied often with considerable feb- 
rile excitement. 

If the difficulty be not arrested here, abscess will 
pretty certainly follow. These abscesses usually 
" point " on the gum, but sometimes, and not very 
unfrequently, unless prevented by making a free in- 
cision through the gum, if the tooth causing it be a 
molar of the lower jaw, on the cheek, leaving an un- 


sightly scar ; or if the tooth be in the front of the 
mouth, under the chin. Sometimes, too, if the tooth 
happen to be a first or second molar in the upper jaw, 
and if, as sometimes happens, the roots of the tooth 
enter into, or come very near entering into, the an- 
trum maxillare, the abscess will be developed in that 

This train of symptoms and consequences is some- 
times produced by the injudicious or careless inser- 
tion of plugs or fillings in the teeth, or a like inser- 
tion of an artificial tooth, by pivot, on a natural root. 

The proper treatment for this kind of toothache, 
as will readily be seen by this description, is either 
to expose and destroy the nerve before suppuration 
has commenced, or to give vent to the pus as soon 
as it is formed. This last can readily be done by 
the use of a very small drill, or trocar, inserted into 
the cavity caused by the caries, at the point nearest 
to the nerve-canal, or if the trouble be the result of 
some other cause than caries, by trepanning the root 
at any accessible point, thus making an opening for 
the escape of the pus ; and if this be done before the 
formation of the sac, and the tooth is such a one 
and so situated as to admit of having the canal or 
canals of its root or roots thoroughly cleansed and 
filled in the manner already described for that oper- 
ation, not only permanent relief, but the future use- 


fulness of the tooth will be secured. But after ab- 
scess is once formed, the case becomes much more 
complicated and uncertain as to the results of treat- 
ment. Still, by judicious and persevering treatment, 
many cases can be cured, and others may be ren- 
dered useful and quite tolerable for years, even after 
this state has occurred. I have seen cases where a 
fistulous discharge had been kept up through the 
gum, from an old abscess, for several years, even at 
that late day entirely restored to health. But in 
relation to the success of treatment much will depend 
on the situation of the teeth, with reference to the 
facility of getting at them, and also to the extent 
of the mischief caused by the abscess. If it has 
caused much necrosis or wasting of the alveolus, or 
if it has denuded the root to any considerable extent 
of its periosteum, treatment will be hopeless. For 
the root of a tooth that is denuded of that membrane, 
beyond a very small portion of its very apex, will 
lose its vitality and act as a foreign substance, keep- 
ing up a constant irritation and discharge of pus. 
And if the abscess have formed within the antrum 
maxillare, or if it have pointed on the outside of the 
cheek, or under the chin, the only prudent course 
left is to remove the tooth, and the sooner this is 
done the better. 

Although trepanning a tooth may afford relief 


from present pain and secure the future usefulness 
of the organ, if pus has formed in the nerve-canal, 
and enough has been forced out to form a sac on the 
end of the root, of the size of a pin's head, it can 
never return through the foramen, to be discharged 
through the tooth ; but if the tooth is trepanned at 
this stage, so as to evacuate what is in the canal of 
the tooth, and thus relieve the pressure, that amount, 
or even much more than that, may be absorbed, and 
no abscess be developed ; otherwise, that will sooner 
or later, and surely, be the result. 

Although what I have already described, is the 
usual course of the progress and development of pus 
confined in the canal of a tooth, sometimes it takes 
quite a different course . of progression, but finally 
terminating in the same result. Thus, the nerve be- 
comes inflamed and suppurates, and a sac is formed 
of even the size of a small pea, and the face swells 
slightly, and so remains, for, it may be, some days ; 
but at length the pain and the swelling subside, and 
entirely cease, while the sac, or rather the yielding 
and protrusion that it causes in the alveolus, can be 
distinctly felt with the finger through the gum, and 
by pressure upon it a sensation of fulness is appa- 
rently felt in the tooth, and so it may remain even 
for months without giving further trouble ; but un- 
less this sac be cut down upon through the gum and 



alveolus, and the pus discharged, it will ultimately, 
from some exciting cause, as the taking of cold, or 
exposure to the excitement of unduly hot or cold 
fluids taken into the mouth, be incited to renewed 
action, burst, and abscess be fully developed. 

Sometimes, but much more rarely, after the nerve 
of a tooth has been destroyed, either by operation or 
otherwise, the canal may become stopped with food 
or other substances, by mastication, so as to prevent 
the egress of pus through the crown of the tooth, 
and abscess be developed in the same manner as if 
the nerve had never been entirely exposed. Some- 
times, too, even when pus has ceased to be secreted, 
gas may be formed, and by being thus pent up may 
be forced through the foramen so as to produce in- 
flammation and terminate in the same result. These 
are the chief and almost only causes of alveolar ab- 
scess, though an accident, such as a severe blow on a 
tooth, is said sometimes to cause it, and undoubtedly 
may do so ; but I have never yet seen one from this 
cause. Sometimes, but very rarely, an abscess may 
form from a dead root of a tooth, but generally such 
cases are simply the filling up of an old abscess which 
originated before the crown of the tooth was broken, 
of which the root remains and continues to act as an 
irritant. Generally when pus is formed around an 
old root of a tooth, it exudes between the root and 


the alveolus without forming a distinct abscess. 
Abscess, caused by a tooth having been decayed or 
denuded of its natural covering, is always formed at 
the point of its root, or if not, I have never yet found 
the sac of an incipient abscess, nor the remnants of 
the sac of an old abscess, at any other point, or part, 
of a tooth. This I write after an experience of more 
than twenty years. In that time I have extracted 
many thousands of teeth ; and in the very commence- 
ment of my professional career I had my attention 
especially directed to this particular branch of their 
pathology, and have, therefore, observed them care- 
fully, and almost constantly ever since, in reference 
to this particular point. 

Inflammation of the periosteum of a tooth, instead 
of being resolved by the formation of pus, sometimes, 
and indeed often causes a deposit of lymph. This 
may be deposited at the bifurcation, or at any other 
part of the root, and has been mistaken by some ob- 
servers — I should rather say writers — for the remains 
of the sac of an abscess. The difference, however, 
may very easily be distinguished, from the patent 
fact, that wherever an abscess or sac containing pus 
has been formed, whether large or small, that part 
of the root under such sac, that is, the part where 
the pus lay, is always denuded of its investing mem- 
brane or periosteum; while, in the other case the 


membrane remains firmly attached to the root and 
the lymph is adherent to it. 

3. Toothache from inflammation of the periosteum. — 
This usually occurs in the periosteum of old roots 
of teeth whose crowns are gone ; or in the periosteum 
of such teeth as have had their internal membrane 
destroyed by escharotics, whose effects have extended 
beyond the pulp to that membrane ; or by the inflam- 
mation caused by the exposure of the nerve, by 
neglect of proper treatment, having extended to that 
membrane ; or sometimes in sound teeth whose an- 
tagonists have been removed, thus leaving them with- 
out the necessary exercise to keep them in a healthy 
condition ; and also by artificial teeth being attached 
to natural ones by clasps, the weight of the artificial 
ones dragging them from their sockets and loosening 

This is the kind of toothache that has sometimes 
been thought to be " epidemic 1" These " epidemics " 
occur after long rainstorms, or other great atmos- 
pheric changes, and as teeth in this condition are 
always liable to be affected by " taking cold," they 
are usually most troublesome after such changes ; 
and as there are always a great many of them in 
every community, such epidemics are pretty frequent. 

The pain, in this kind of toothache, is described as 


of a more dull, heavy character, and the tooth though 
sore is not so extremely sensitive to the touch as that 
last described. This kind may readily be distin- 
guished from the others by observing the condition 
of the gum, which presents a livid appearance along 
the course of the root, with more or less swelling ; 
generally, however, with but little, showing a chronic 
state of inflammation. There may be a kind of puffi- 
ness opposite the point of the root, and perhaps a 
slight discharge of pus may ooze out by pressing 
slightly upon it with the finger. This is occasioned 
by the partial filling up of an old, and most likely 
fistulous abscess, which is a very common cause of 
this affection. There is but rarely any, or at most 
but little swelling of the face, accompanying this 
kind of toothache. The pain, though generally not 
very severe, is very annoying, constant, and trouble- 
some. It may usually be palliated by local bleeding, 
by holding cold water in that part of the mouth, or 
by other antiphlogistic remedies ; and if the pain be 
caused by the dragging of artificial teeth or the loss 
of the opposing teeth, a removal of the irritating 
cause and frequent friction of the gum with a brush, 
accompanied with some strongly astringent and 
stimulating wash, may effect a cure ; but if the dis- 
ease is connected with a dead tooth, or an old root, 
the only radical cure will be extraction. 



4. Toothache from inflammation of the dentine. — This 
kind of toothache is produced by the use of the file, 
or other mechanical injuries, and by caries— and much 
the most frequently by the latter — and in most cases 
is most severe when the caries has extended only 
through the enamel, or but very slightly into the 
dentine; and for the probable reason, that here, 
that is, at the union of the enamel with the den- 
tine, is the termination of the nerve-fibres that ram- 
ify the dentine; the greatest amount of sensibility 
always being found in any part, at the termination 
of the nerves. This kind of toothache is usually de- 
veloped by the contact of cold air, acids, sweets, or 
hard substances, coming in contact with the inflamed 
dentine ; and generally subsides when such irritant 
is removed, or ceases to act. The intensity and the 
persistency of pain from inflammation, other things 
being equal, depends chiefly on the degree of organi- 
zation or vascularity and vitality of the part. Den- 
tine, having but a low grade of these, is not suscepti- 
ble of the same degree of inflammation as the soft 
parts, or even as other bones which are more highly 

Some teeth are much more highly organized than 
others : for example, persons of a strumous diathesis 
have softer and more highly organized teeth than 
those with better constitutions ; and children and 


youth, than those advanced in years ; hence the teeth 
of the young and those with bad constitutions are 
much more liable to suffer from inflammation of the 
dentine than those who are older, and the healthy 
and strong. 

I am fully aware, in the outset, that in calling 
this affection, inflammation, I am treading on contro- 
verted ground — that many contend that dentine is 
not susceptible of true inflammation. What then is 
the cause of this sensitiveness, and this pain ? "Will 
calling it " exalted sensibility," or some other name, 
change the facts or aid our understanding of them ? 
It is true that parts that have no circulation can 
have no inflammation. Enamel is never inflamed — 
is rarely sensitive. It is also true that dentine can- 
not manifest all the characteristics of inflammation 
as manifested in the soft parts. From the density 
of its structure it is not susceptible of swelling. 
Neither are any of the common bones ; but does any- 
body, on that account, deny their susceptibility to 
inflammation ? From the small amount of the vital 
fluids circulated in the teeth, they are not susceptible 
of perceptible increase of heat. Is that condition 
perceptible in inflamed bone ? Redness of the parts 
is another concomitant attending inflammation of 
the soft parts, which, usually cannot attend, or at 
least be appreciated in, inflammation of the dentine. 


Red globules of blood do not permeate healthy den- 
tine ; and most writers have contended that they do 
not under any circumstances. This, my own ob- 
servation has satisfied me, is not correct. Some 
highly organized teeth — though I admit the cases 
may be rare — may, and do, circulate red blood when 
in a state of inflammation. 

In 1845, I was applied to by Miss IN"., a young 
lady of about eighteen years of age, of a spare habit 
and of a very marked cachectic diathesis, to fill 
several of her teeth. Each of her four upper incisors 
had rather a large cavity in its anterior or labial sur- 
face. In rem o ving the decayed portions, preparatory 
to filling, I found the dentine extremely sensitive ; 
so much so, that I was obliged to make some appli- 
cation to obtund it before I could complete the oper- 
ation. But I finally succeeded in doing it, and, for 
the time, very satisfactorily. But in tivo or three 
days my patient returned complaining of great pain 
in her teeth, and contended that the pressure of the 
gold within the cavities caused the pain. On ex- 
amination I found that the crown of each of them 
had a very decided tinge of red. Thinking it possi- 
ble that I might, unwittingly, have exposed or 
wounded their pulps, and that the fillings were press- 
ing upon them and causing the pain, and that possi- 
bly, too, blood was extravasated under the fillings, 


thus causing the redness, I removed the fillings. 
This immediately gave her some relief — it removed 
the sensation of pressure that she had complained 
of, though it did not afford entire freedom from the 
pain. . 

After removing the fillings, I made a careful ex- 
amination of the cavities, but could find neither ex- 
travasated blood, nor the least point of exposed 
membrane in any of them ; but the dentine over the 
whole surface of the cavities was quite red and very 
sensitive — much redder, of course, than it appeared 
when seen through the enamel before the fillmsrs 
were removed. I made an application of morphine 
to the cavities, which I also renewed once or twice, 
and in a few days the redness and most of the sensi- 
tiveness had left them. I then carefully refilled 
them, she still complaining of some pain from the 

In a few days she returned again, with the teeth 
looking quite as red, or even redder than before, and 
complaining of the same kind of suffering as before, 
and, perhaps, in a greater degree. I again removed 
the fillings and applied the morphine with the same 
result as before : and after some further treatment 
to obtund and to prevent the sensibility, I again re- 
filled them, and without any recurrence of inflamma- 
tory symptoms. 


It is perhaps but just to remark, iu connection 
with this case, that with all the care I could use in 
filling those teeth, about one year at a time was all 
that I could succeed in making fillings remain in 

Two other gentlemen, in whose skill in such opera- 
tions I had great confidence, and from an observa- 
tion of the results of their work for several years, 
tried some of them one or more times each, and 
with a knowledge of the fact that I had already tried 
each of them at least twice, and that I believed they 
could not be so filled that the operation would be 
permanent, as a further stimulant to their exertions ; 
bat, to their confessed disappointment, with no better 

About four years after my first operations on her 
teeth, this young lady died of phthisis pulmonalis. 

Since my experience with this case, whatever my 
convictions might have been before, I have had no 
doubt that dentine, in some instances, at least, is 
susceptible of inflammation, and that too in a pretty 
high degree. 

This, I am aware is an extreme case, but it is not 
altogether an isolated one. I have seen others of a 
similar kind, but no other so bad as this. But if 
this case stood entirely alone, it would prove, to my 
mind, that dentine is susceptible of inflammation, 


and it would indicate to me that the sensitiveness, 
so frequently observed in the teeth when but slightly 
decayed, is true inflammation, but only of a lower 
degree than this. But it is not necessary to resort 
to such extreme cases to establish this doctrine. 

That dentine is endowed with all the essential 
characteristics necessary for the development of in- 
flammation, as vitality, nutrition, and secretion, is 
easily demonstrable. 

That it is endowed with vitality is evinced by its 
sensitiveness when in a normal state, by its greater 
sensitiveness when diseased, and by its greater pow- 
ers of resisting the influence of chemical agents, 
when in a healthy condition, than after its vitality 
has been destroyed. Dead teeth decay much more 
rapidly in the same mouth than living ones; crowns 
of natural teeth engrafted on the roots of other teeth, 
as artificial substitutes, never last at most but very 
few years. 

That it receives nutrition, from both its internal 
membranes and from its periosteum, needs no argu- 
ment now. If that is not an essential part of the 
office of both these membranes, they would seem to 
have no office ; and nature never makes or tolerates 
useless things. 

That it is endowed with the function of secretion 
and reproductive — recuperative — energy to some ex- 


tent like other bones, though, not, so far as known, 
to the extent of the union of fracture, has been 
abundantly proved in numerous instances by the fill- 
ing of teeth where a portion of inflamed, softened 
and exquisitely sensitive dentine has been left in the 
bottom of the cavity, the better to protect the nerve 
of the tooth, and which by thus being protected 
from external influences, after a time, on removing 
the filling, has been found, without undue sensitive- 
ness,, firm, solid, and healthy. 

It is no uncommon occurrence either for a tooth 
to decay to a considerable extent, with the usual 
sensitiveness accompanying decaying dentine, and, 
after a time, from a change in the secretions of the 
mouth, or other circumstances that originally caused 
the decay, for the inflammation and sensitiveness 
to subside, the process of decomposition to cease, and 
the dentine, that had been softened, to become hard 
and sound — harder by far than ordinary healthy 
dentine, and so to remain for many years, and with- 
out any local treatment. Is not this the effect of 
recuperative vital energy ? 

I know of one case where a right central upper 
incisor commenced to decay, on its anterior or labial 
surface, before the crown of the tooth was more than 
half projected from the gum ; and by the time it had 
acquired its full length the cavity was very large, 


occupying about one-fourth of the whole anterior 
surface of the tooth, and quite deep. The process 
of decomposition finally ceased, exfoliation undoubt- 
edly took place, and the tooth was restored to com- 
plete health ; the only apparent defect in it be^ng a 
somewhat corrugated appearance, and a very slight 
discoloration of the part. And now, at more than 
forty years from the commencement of the process 
of decay, the tooth is entirely healthy and strong. 
That tooth is my own. 

That decaying dentine is susceptible to extreme 
sensitiveness and pain — most constant concomitants 
of inflammation — none can deny ; and if the affection 
be not inflammation, what other appellation shall we 
use better to describe the condition ? 

In most cases this " exalted sensibility " and pain 
can be alleviated 'by some soothing application, or 
removed by carefully cutting away a thin layer of 
the diseased dentine, and wholly removed and pre- 
vented by cutting away all the diseased portion and 
filling the cavity with suitable materials, so as to 
prevent the contact of all irritating substances. 

5. Toothache from Sympathy. — This most commonly 
occurs when the nerve of one tooth is inflamed, from 
exposure or other causes, or its periosteum is inflamed, 
and the pain is referred to some other tooth ; and 



that other quite as likely to be entirely sound as 
diseased. This is a circumstance of very frequent 
occurrence when one of the lower wisdom teeth is in 
fault ; then the pain is quite as apt to be referred to 
one of the bicuspidati, or one of the incisors, in either 
jaw, on that side of the head, as to the tooth that is 
diseased. In such cases, too, the pain is often com- 
plained of in the ear, temple, and scalp, and sometimes 
soreness of the scalp is also complained of. 

A careful examination will settle the point, and it 
is a good rule never to extract any tooth without 
being able to give some good reason for it, and a 
better one than that the patient wishes it done, or 
thinks that it aches. This rule, carefully observed, 
would save a great many valuable teeth from being 
simply sacrificed. 

Sometimes, too, nervous irritation in other, and 
even remote parts of the system, produce pains that 
are referred to the teeth, as uterine affections, affec- 
tions of the stomach, &c. Quite recently, a very in- 
telligent lady related to me some of her own experi- 
ence, which forcibly illustrates this point. Some 
years ago she suffered from a very severe attack of 
toothache. She applied to her family physician for 
relief, and he, not discovering the cause of her pain, 
recommended her to a dentist. He, not observing 
the rule given above, extracted several of her teeth, 


at different times, but without affording any relief. 
And her sufferings were so intense that she said she 
believed she should have had all her teeth extracted, 
if she had not, accidentally, cured herself. She found 
herself suffering from acidity of the stomach ; and 
for that, took a dose of the carbonate of soda, when 
almost immediately, and to her great delight, she 
found her toothache had entirely left her. And, 
several times afterward, she said, she had had tooth- 
ache from the same cause, and cured it in the same 
manner. Of course to extract a tooth expecting to 
remove the toothache produced by such causes would 
be the extreme of folly — more, it would be wicked- 

A careful examination into all the circumstances 
and an application of the rule just given, must be the 
guide in all such cases. 

6. Toothache from Exostosis. — Exostosis of a tooth, 
is a bone-like deposit, of about the hardness and of 
an appearance similar to the cementum or outer 
portion of the roots of the tooth ; the cause of which 
is but very imperfectly, if at all, understood. It gen- 
erally commences at, or very near, the point of the 
root, but may commence at any other point, and is 
said sometimes to have been found extending even 
to their crowns. 


The pain from this disease, when it occurs, % is prob- 
ably caused by the pressure it makes on the nerve. 
Sometimes it is severe when the deposit is quite 
small, in other cases it is slight, or there may be 
none at all, even where the deposit is quite large. 

Roots of teeth are frequently found with such en- 
largements upon them, that have remained in the 
mouth years after their crowns have been entirely 
removed by decay, and without giving any pain or 
cause of complaint. "Whether the deposit was made 
before or after the decay of the crown, and loss of 
the nerve, is extremely difficult to determine. Of 
course after the nerve was gone, it could not impinge 
upon that to cause pain. But when it does cause 
pain, whatever its manner of doing it may be, the 
only known source of remedy, or relief, is extraction. 

The diagnosis of this kind of toothache is perhaps 
more difficult and uncertain than that from any other 
cause, and particularly so where the deposit is small ; 
as the tooth then presents no external sign of disease. 
When it is of considerable size, it generally makes 
a corresponding protrusion of the alveolus that can 
be felt with the finger. Probably the surest test, 
when the enlargement cannot be felt beneath the 
gum, is rapping the tooth lightly with some small, 
hard instrument, which, if the cause of the pain be 
exostosis, will, probably, for the time increase it. 


Great caution, however, should be taken about ex- 
tracting teeth where no other cause can be found 
than the exacerbation of pain by jarring the tooth, 
or by even very lightly touching it. It is well to re- 
member that this is not a common cause of tooth- 
ache ; and that without such caution serious mistakes 
may be, and have been committed ; in illustration of 
which I will relate two rather marked cases. 

In the autumn of 1858, a gentleman of this city, 
of about thirty years of age, came to ask my opinion, 
and advice, in relation to a very severe pain which 
he had been suffering, at intervals, for two or three 
years ; and which for the last year had been so fre- 
quent, and so severe, that he had been obliged to 
relinquish a very lucrative business, luckily, however, 
on a competency. His pain and suffering he referred 
to the root of the lower canine tooth. 

On inquiring into the history of the case, I learned 
from him, that he had been suffering most intensely, 
at intervals, as already remarked, for some years. 
That the pain came on in sudden paroxysms, of which 
sometimes, he would have very frequent successions 
during several days or even weeks, and again he 
would be entirely free from them for a longer or a 
shorter period. These paroxysms seemed to be in- 
duced from the slightest causes, as a touch of the 
tooth, or even of that part of his face, and on that 



account, sometimes for several days together, lie had 
hardly been able to take food enough to sustain life; 
and had been reduced in weight between thirty and 
forty pounds. He had once had the mental nerve of 
that side excised, with no effect, except the partial 
paralysis of his lower lip. As his trouble was in- 
creasing, and as his physicians could find no other 
cause for the pain, and especially as he so constantly 
referred it to that tooth, and as so slight a touch 
upon it brought on the paroxysms of pain, although 
the tooth had no appearance of disease, they advised 
the removal of the tooth ; and about three months 
before his consulting me, he had applied to a young 
practitioner of dentistry to have it extracted. He 
attempted it, without success, but broke off the tooth 
in part at, and a part below the edge of the alveolus ; 
and, as he could not succeed in removing the root, 
decided that it must have exostosis of the fang, and 
so told his patient ; and that it could not be removed 
without first cutting away the alveolar process to, 
or near the point of the root, which was also repre- 
sented to him as quite an important surgical opera- 
tion. It was on that account chiefly that he was 
induced to apply to me. 

On hearing his account, and on a close examina- 
tion of the case, I was satisfied that it was a case of 
pure neuralgia ; that there was no exostosis, and that 


the tooth had nothing to do in causing his pain, and 
that its extraction, or any other mere local treat- 
ment, would probably have just as little to do with 
removing it, and so advised him. But I further ad- 
vised him, that as the tooth was now broken, and 
thereby rendered useless ; and as the removal of its 
root might be a relief, and satisfaction to his mind, 
he had better now have it removed ; and I assured 
him if he wished it, I could remove it without any 
unusual difficulty. He preferred not to have it done 
just then, but said he would return in two or three 
days to have the operation performed. But mean- 
while he was called suddenly to go to Philadelphia ; 
and while there having a severe attack of his neu- 
ralgia, he applied to some gentleman there — I am 
glad I do not know to whom — for advice. This 
gentleman, probably relying on the diagnosis of his 
young predecessor, who broke the tooth, determined 
that it was necessary to extract the root ; and either 
for an excuse for demanding a larger fee, or some 
other unknown cause, determined that in order to 
enable him to do that, it was necessary for him first 
to extract the adjoining bicuspid, which was a per- 
fectly sound tooth ! This he did ! and then chiselled 
away the septum between it and the broken root, in 
order to get that out, which, when he had gotten it 


out, proved not only to have no exostosis, but to be 
uncommonly slender and pointed ! 

And worst of all, after having sacrificed two per- 
fectly sound teeth, the patient was not in the least 
relieved of his sufferings. His disease was beyond 
reasonable doubt constitutional, not local. 

AVhile on this subject of neuralgia, as it is too 
common a cause of mistakes of this kind, I will re- 
late another case, analogous to this. 

In 1857 I was called in consultation with a medi- 
cal gentleman to see a young lady, of about seven- 
teen years of age, small in stature, of delicate con- 
stitution, and of nervous temperament. For several 
months she had been suffering most intensely from 
neuralgic pain?, which she referred to her teeth. On 
examination I found all the teeth she then had, as 
well as her gums, and all other parts of her mouth, 
apparently in the most perfectly healthy condition; 
but she had already had all the molars and nearly 
or cpiite all the bicuspidati of both jaws extracted, 
with the hope of finding relief. She now wished to 
have, and had insisted on having, one of her upper 
canine teeth removed ; but the physician then in 
attendance, both from a knowledge of the fact that 
she had experienced no relief from the removal of 
the many that had already been sacrificed, and from 
the firm belief that she needed constitutional, and 


not local treatment, advised the asking of my opin- 
ion ; and, at his request, I was therefore called in 

I fully concurred in her physician's opinion ; and 
though tearfully implored hy the young lady, de- 
clined to extract the tooth ; knowing, and assuring 
"both her and her widowed mother, that it would be 
but a sacrifice of the tooth without affording the 
least hope of relief. 

I am sorry to feel compelled to add, that this 
young lady went to the gentleman who had already 
mutilated her so sadly, by taking out the most of 
those she had already lost ; and he, although he was 
aware of the opinion, at least, of her medical adviser, 
and of the fact that what he had already done had 
been of no avail, was, either through ignorance or 
cupidity, or both, induced to extract the tooth, and 
of course with no better results than had attended 
his former operations. Great care then should be 
taken not to be deceived into the belief that all pain- 
ful affections referred to the teeth are toothache, and 
require the extraction of the teeth. 

But there are some affections which frequently 
come under our observation and care, and which 
often require the extraction of the teeth, that are 
not properly toothache, though generally so denom- 
inated, of which we must not here fail to speak. 


One of the most common and painful of these is 
that caused by the cutting of the wisdom, and more 
especially of the lower wisdom, teeth. 

There are several kinds of difficulty and trouble 
from this cause. One common one is owing to the 
fact that these teeth are very liable to assume irreg- 
ular positions : as, for example, the grinding surface 
of the tooth, or, in such a case more properly, its 
multicnspidated surface, may present itself to the 
cheek, when, if its cusps happen to be pretty sharp or 
a little rough, they may produce irritation or inflam- 
mation, swelling and pain ; and on this account, unless 
a file can be brought to bear upon them, so as to re- 
move such sharp or rough points, may require to be 

A file may be used to remove such sharp points 
of enamel without producing soreness, as would be 
the case if the dentine were exposed, or injured by 
it ; and although on the enamel its use is likely to 
cause decay in such cases, it is the less of two evils, 
and is therefore allowable. 

But a more common and much more troublesome 
condition is where, from the narrowness of the space 
allotted to them at the posterior portion of the jaws, 
there is not room for their full development. If, in 
such cases, the upper tooth precedes the lower for a 
considerable length of time, as frequently happens, 


so that the upper has acquired its full length, or by 
having nothing to oppose it, perhaps a little more 
than its proper length, thus occupying more than 
its due proportion of the limited space allotted to 
both, when the lower advances near to the surface 
it raises the gum so as to bring it in contact with 
the upper tooth at every occlusion of the jaws. 
This bruises the gum, perhaps already irritated, and 
produces inflammation, great discomfort, and pain. 
Here, sometimes, an incision, or sometimes better, a 
small excision, may give entire relief, and avoid all 
further trouble. But if the space between the jaws 
be too narrow ultimately to admit the protrusion of 
the full length of the crowns of these teeth, as there 
can be no attachment of the gum to the enamel of a 
tooth — enamel having no periosteum — a cul-de-sac 
or pouch will be formed, of a depth equal to the un- 
protruded portion of the crown. And if there be 
only room — as is by no means uncommon — for the 
protrusion of one or more of its cusps before meeting 
the opposing tooth, then this sac will be of a depth 
equal to the whole length of the crown. This sac 
forms a ready receptacle for food or any other mat- 
ters taken into, or secreted by, the mouth, to lie in 
and decompose ; and this may produce inflammation, 
ulceration, the burrowing of pus deep in the cellular 
tissue ; forming abscess, causing necrosis, exfoliations, 


and all the other ills consequent upon severe inflam- 
mation. These more severe lesions consequent upon 
the coming of the wisdom teeth, so far at least as 
my observation goes, are confined to the lower jaw ; 
and for the reasons, first, that I believe the upper 
wisdom teeth are usually first in coming, and are 
therefore the most fully protruded through the gum ; 
but chiefly for the reason that if food or other sub- 
stances were forced, by mastication or otherwise, 
under the edge of the gum on the upper jaw, the 
force of gravitation would constantly tend to remove 
it, and would, generally, do so before it could do 
much harm ; whereas in the lower jaw, the same force 
would as constantly tend to keep it there. 

When the parts are in this condition, the only 
effectual remedy that I have ever found, or seen 
tried, is the removal of the teeth ; thus allowing the 
gums to contract, heal, and obliterate the sacs. 

I advise feelingly on this subject, having been 
obliged to have both my own lower wisdom teeth 
removed for this cause. 

A deposit of tartar upon the teeth often produces 
a low grade of inflammation of the gums and peri- 
dentinum, usually taking a chronic form. This some- 
times produces a dull pain — pity it did not always 
produce acute pain and from its earliest stages — and, 
for the relief of this pain, we are sometimes called 


upon to extract the teeth. The entire removal of 
the tartar, and proper local treatment, which should 
generally consist of a wash of some of the stronger 
vegetable astringents, made stimulating by the addi- 
tion of a little of some of the essential oils, or alco- 
hol, and the frequent friction of a brush, and, if need 
be, in addition, some constitutional treatment, will 
generally effect a speedy relief and an effectual cure. 
Sometimes, however, especially on the lower teeth, 
the deposit, if long neglected, may have extended 
so near the point of the root as to render the entire 
removal of it impracticable, then extraction some- 
times may, though very seldom, be required to afford 

Sometimes when the teeth naturally stand slightly 
apart, or have been separated by the file or other- 
wise, food, while being masticated, may be forced 
through these spaces upon the gum with sufficient 
force to induce inflammation, and thus produce in- 
convenience and pain. The pain in such cases is 
generally not very severe, and, with a little care on 
the part of the patient, is not of very long duration. 
To extract a tooth for such a cause would, of course, 
be too great a sacrifice. 

From the foregoing remarks we may readily de- 
duce some pretty definite general rules to guide us 
in the extraction of teeth, or at least by which to 



determine pretty nearly what teeth require extract- 
ing, and what onght not to be extracted. 

1st. Any aching tooth, the crown of which is so 
far destroyed by caries that it cannot be restored to 
usefulness by being properly filled, should be ex- 
tracted ; unless the tooth be one of the upper incisors 
or cuspidati, the roots of which are often important 
on which to engraft artificial crowns. In such cases 
great pains should be taken to preserve the roots and 
to restore them to health, irrespective of the state of 
their crowns. 

2d. Any tooth whose pulp is exposed, and either 
the tooth or the cavity in the tooth is so situated 
that it is impossible to get at and to thoroughly 
cleanse and fill its roots, as well as the cavity caused 
by the decay. 

3d. All aching teeth that have caused abscesses 
that have produced, or are producing, such lesions of 
the surrounding parts as to preclude a reasonable 
prospect of cure. 

4th. Such aching teeth as have exposed or in- 
flamed pulps, or incipient abscess, or have become 
painful from any other cause, and have already been 
rendered useless by the loss of their antagonists in 
the opposing jaw. 

5th. . All old roots of teeth that produce pain, 
from inflammation, or whose ragged edges are pro- 


ducing inflammation in the surrounding gums, or are 
in any other way causing injury. 

6th. Wisdom teeth not having room between the 
jaws for their full development, and which from that 
cause, as before described, are producing inflamma- 
tion and pain. 

7th. All painful teeth unmistakably affected with 
exostosis. And besides these causes, 

8th. It is sometimes proper to remove even healthy 
and sound teeth: as where, for example, one has 
already lost most of his teeth, and those remaining 
are useless by not standing opposite* to each other ; 
or if there is only an occasional one left in the mouth, 
and the person wishes to be supplied with artificial 
substitutes, which by this means ma}' be made much 
more serviceable than thev can be with a few scatter- 
ing natural teeth left remaining. But here, and in 
all other cases, too much care cannot well be used to 
avoid the removal of teeth that are useful, or that 
by suitable skill and care can be made so. 

But when any of the conditions exist in such force 
as to require the extraction of a tooth, I scarcely can 
conceive of any circumstance that would contraindi- 
cate the immediate performance of the operation, 
though some writers point out many such circum- 
stances. A few of them we will examine. 

I have seen the following conditions set down as 


indicating the necessity of great care — by which I 
suppose is meant unusual care — in the operation of 
extraction, or of prior treatment, or of forbidding 
the extraction of the teeth altogether, to wit : 

"Extreme debility." 

" Great nervous irritability." 

" Excessive local inflammation, especially where it 
tends to the othei' parts." 

" Much irritability of the parts immediately con- 
nected with the teeth." 

" Pregnancy, and all uterine irritations."* 

Now to my "mind, most, if not all of these condi- 
tions, instead of being causes for altogether refrain- 
ing from extraction or of delaying that operation, 
would be cogent arguments for the performance, and 
for the immediate performance of the operation. 

All possible care and gentleness should be used 
under all circumstances where extraction is required. 

Now, since there can hardly be a better established 
principle of surgery or medicine than that the read- 
iest way to remove any disease is to remove its cause, 
I can scarcely conceive of a more sure cause of debil- 
ity than the severe sufferings from toothache, and 
the loss of appetite, and sleep and rest occasioned by 
such suffering ; therefore, if the pain could not other- 

* Taft's Operative Dentistry, p. 342. 


wise be readily effectually palliated so as to give rest 
and comfort, and if the patient were not already 
moribund, I should regard debility, to almost any 
extent, an urgent cause for extraction, and that im- 
mediately, and should expect by it, not to increase, 
but to relieve the debility. And as I can scarcely 
conceive of anything more directly calculated to keep 
up and to increase " great nervous irritability," or to 
excite and maintain " excessive local inflammation," 
whether " it tends to the other parts" or not ; or to 
excite "much irritability of the parts intimately 
connected with the teeth," than a diseased and aching 
tooth, if I saw any or all of these conditions accom- 
panying, I should consider each one an additional 
reason for the immediate extraction of the irritating 
cause. This would certainly be my general rule, 
though there might possibly, sometimes, be such ex- 
treme cases of irritation and debility as would require 
delay, for improvement in the general condition, lest 
the shock of the operation prove too severe for the 
enfeebled powers to endure ; but whenever such a 
case occurs, great care must be taken " that the 
patient does not die in getting well." 

Of the expediency of extracting teeth, in ordinary 
cases, during pregnancy, there may perhaps be better 
grounds for different opinions. That there is a pretty 
strong sympathetic influence existing between the 



uterus and the teeth, and manifested most particu- 
larly when that organ is in the gravid state, there 
can he no doubt, as it is not uncommon when in that 
state, or when it is in an irritable condition from 
other causes, for it to produce strong sympathetic 
influences even on sound teeth, so as to occasion 
great discomfort, and lead to the impression that 
they should be removed. Too much care, of course, 
cannot be observed to avoid falling into such mis- 
takes. But, although we admit the great sympathy 
between the teeth and uterus, and that any great 
violence to the teeth may make a very distinct im- 
pression there, and especially when in the gravid 
state, I cannot regard pregnancy as a valid objection 
to the extraction of aching teeth, the pain of which 
cannot otherwise be palliated. By theory, and by 
practice, I have ever maintained that the danger of 
abortion is greater from the constant pain and sym- 
pathetic irritation, and the debility consequent upon 
the loss of rest and sleep, than by the operation ; and 
although I have extracted teeth for many women 
;vvhile in that condition, I have never yet known any 
untoward results to follow. Still, I can well conceive 
that in a feeble person, of great nervous irritability, 
especially if she had previously been subject to abor- 
tions, the extraction of a tooth, and more particularly 
if the operation be roughly performed, might produce 


that result. Therefore, in such cases, it would be 
but prudent to try the effect of palliatives ; and if 
these afford a tolerable degree of comfort, extraction 
is safer omitted ; but if these do not afford relief, it 
is but a choice between two evils, of which extraction 
will generally be found the less, but circumstances 
may sometimes render it the greater ; of which every 
judicious practitioner will necessarily judge for him- 
self at the time. 



Sec. 1. Having now studied the anatomy of the 
teeth and jaws, and, from a consideration of the 
pathology of toothache, seen what teeth require ex- 
traction, we next come to consider the instruments 
used, and those most appropriate to he used, in the 
operation; as well as the most proper methods of 
using them. They are of various kinds, and to he 
fully prepared to extract all classes of teeth, and 
under all conditions and circumstances, requires a 
considerable variety ; hut there are some kinds of 
instruments, and in very general use, that ought 
entirely to be laid aside, and never more to be used ; 
and many instruments of a proper kind — or at least 
bearing the names of the proper kinds of instruments 
— are so badly constructed as to render them but 
little, if any, less objectionable. Some of these I 
shall describe, and the mode of their action, only to 
caution all, and especially beginners, against their 


The instrument which is probably in more general 
use for the extraction of teeth than any other single 
instrument, and by the use of which more accidents 
and injuries are committed than by all other extract- 
ing instruments combined, is the turnkey ; therefore 
from its great power to do evil, as well as its exten- 
sive use and antiquity (having been invented, as it is 
said, near the beginning of the last century, or about 
one hundred and fifty years ago), seems to require 
some notice. 

This instrument of torture, and of dread, consists 
of a steel shaft about five inches in length, and the 

Pig. 20. 

fourth of an inch in thickness, either straight or 
bent, much or little, and in various ways, the better 
to facilitate its application. On one end of this 
shaft is a horizontal projection or fulcrum, of vari- 
ous lengths, sizes, and shapes, and either fixed to the 


shaft or attached to it by a kind of hinge, to suit the 
fancy of the maker or operator. To this end of the 
shaft, too, is fixed a movable hook or claw, with 
which to grasp the tooth. On the other end of the 
shaft is fixed a transverse handle, about three and a 
half inches loii£. 

When the instrument is applied, the fulcrum rests 
upon the gum and edge of the alveolar process on 
one side of the tooth to be operated on, while the 
hook or claw is placed in contact with its neck, on 
the other side. 

" This instrument may be regarded in the light 
of the wheel and axle ; the hand of the operator act- 
ing on two spokes of the wheel, to move it, while 
the tooth is fixed to the axle by the claw." 

It is plain from this description, or from a glance 
at the instrument, and the situation of any tooth in 
the jaw, that the lowest point at which the claw can 
be brought in contact with, and take hold upon the 
tooth, can be but very little, if any, below the level 
of the bearing of the fulcrum on the opposite side ; 
and therefore the force applied to the tooth is not in 
the direction of the axis of the tooth and its socket ; 
but, even when best applied, under the necessities of 
the case, it must be diagonally across it ; and that, 
by this means, that part of the tooth next to the 
fulcrum must impinge strongly on that side of the 


alveolar cell, while the end of the root, or roots, 
must as strongly impinge on the bottom of the cell 
at the opposite side, thus necessarily requiring a 
greatly unnecessary amount of force, by this indi- 
rect manner of applying it, as well as to overcome a 
large amount *of friction occasioned by this indirect 
or lateral force. It is plain, too, in theory, and prac- 
tice has a thousand times proved it, that if the tooth 
be an upper molar, with roots much divergent, some 
or all of them must be broken, or the alveolus be 
wrenched away, before the tooth can be removed 
from its socket, by applying force in that direction. 

All this is on the supposition that the instrument 
is as well constructed and applied as it can be, with 
the point of the claw below the bearing of the ful- 
crum. But supposing that, by carelessness, inad- 
vertence, or accident, the fulcrum is below or on a 
line with the point of the hook, then the only action 
of the force applied is across the tooth, and the only 
effect must be either to break it, or to split and 
wrench away the side of the alveolus, probably ac- 
companied with bruising and laceration of the gums ; 
all or either of which are unpleasant accidents. 

Another objection to this instrument not to be 
overlooked or ignored, is the liability, from the sud- 
den starting of the patient or from other causes, of 
the instrument to slip, even in careful hands, from 


the tooth to which it was applied, to the space be- 
tween it and the tooth next in front of it, or even to 
the next tooth, thus taking out two teeth instead of 
one, or at least the wrong tooth ! — a serious and a 
mortifying accident, that many a man has been sub- 
jected to, and by which many a patient has suffered. 

Much useless labor and thought has been expended 
in trying to invent a key, whose force should act in 
the line of the axis of the tooth to be removed ; but 
if it could be accomplished, the labor and the thought 
would still be useless, for the instrument when done 
would be altogether objectionable, and even wholly 
inadmissible, in practice ; for it must require a force 
in removing a tooth sufficient to rupture all the 
membranes at the same instant, and if its roots di- 
verge from each other, to break them or tear up the 
alveolar processes. 

The key, in any form, is a powerful instrument, 
but, at the best, a dangerous and a barbarous one. 

During the first ten years of my professional life, 
I used it often, and because I was so taught ; and 
although I never had any very serious accident occur 
from the use of it, I never once in all that time took 
it in my hand, to extract a tooth, without feeling a 
degree of anxiety about the result. 

The Conical Screw is another instrument that has 
been long used for extracting certain teeth, and its 


virtues much vaunted, which is of very little use 
except in theory. It is at most applicable for the 
removal of the roots of teeth in the upper jaw, and 

Fig. 21. 

more particularly to those of the incisors and cuspi- 

It is applied by inserting its point into the decayed, 
and thus enlarged, canal of the root, and by a gentle 
force and a rotary motion causing it to cut a thread 
in the root, corresponding to the thread in the screw, 
and thus securing a hold by which to remove it. 

The chief objections to this instrument are, that 
it is but seldom that it can be made to cut a thread 
in the root of a tooth strong enough to answer the 
purpose intended ; if the root is any ways long and 
firmly set, and if it be but short and frail, before a 
sufficient thread be cut by which to remove it, it will 
probably be split into fragments, and the operation 
thus complicated. And when it can be made to 
answer, especially if the root be sore, from inflamma- 
tion, it will cause a great deal more pain than a more 
suitable instrument. And finally, it is — of no practi- 
cal account. 



A great deal of angry controversy was carried on, 
a few years ago, in some of the dental journals, as 
to who was entitled to the honor of inventing an in- 
strument, called a compound screw forceps, and com- 
bining the screw and the forceps. It consists of a 
pair of common straight forceps, with a conical screw, 
with its shaft inserted into a cylinder, one end of 
which is let into the joint of the forceps, so that it 

Fig. 22. 

can play between the blades like the clapper of a bell, 
and the screw so arranged by a spiral spring^in the 
cylinder, that it ,can be thrust out from the blades 
somewhat like the tongue of a serpent, to be seized 
by the blades of the instrument, and screwed into 
the hollow root ; and then the blades opened, and 
made to grasp the outside of the same. 

The operator, however, will generally find, in 


using this instrument, that after he has carefully in- 
serted the screw into the root, and carefully applied 
the blades upon it, and carefully made rotation and 
traction, he has very carefully brought away his 
whole instrument, and a small portion of the almost 
friable edges of the root, and nothing more, leaving 
the greater part, and the important part, of it in the 
jaw, to be removed by some more effective means. 

I once spent considerable time, labor, and pains, 
in describing, for the inventor, what I believe was 
the first instrument of this kind ever made ; but the 
instrument, when perfected, was never, to me, worth 
half the trouble it took to describe it. 

There are various hooks and punches, for removing 
roots of teeth ; and chisels for chipping away the 
alveolar processes, to enable the operator to grasp 
roots and broken teeth, and to facilitate their re- 
moval, which are often, if not most generally, found 
in extracting cases, all or any of which may be made 
to answer the purpose for which they are intended, 
but are very ill adapted to the purpose, and ought 
to be regarded as only so much useless lumber. 

But to be fully prepared for all cases and emer- 
gencies that occur in extracting teeth, quite a variety 
of instruments are certainly needed, but if they are 
good, well made, properly constructed by being well 
fitted to the teeth on which they are intended to act, 


a smaller number will be much more efficient, and 
useful, than ever so many of bad quality, bad con- 
struction, and ill adaptation. 

But to be tbus thoroughly prepared for all cases 
in both temporary and permanent sets, each extract- 
ing case should be supplied with at least fifteen pairs 
of forceps. And, although a smaller number may be 
made to answer, in all ordinary cases, circumstances 
arise, and cases occur, where even more than this 
will be found convenient. Of these there should be 
three pairs of straight forceps, designed chiefly for 
the upper incisors and cuspidati, one pair of upper 
bicuspid forceps, two pairs upper molar, one pair 
lower incisors and cuspidati, two pairs lower cuspi- 
dati, and one pair of lower molar forceps, a similar 
set of small molar, adapted to the size of the tempo- 
rary set, and one pair of quite small straight forceps 
for the incisors of the temporary set ; these will also 
be found useful for removing loosened roots or frag- 
ments of bone ; also one or two pairs for irregular 
teeth, and one pair of quite small root-forceps for the 
lower jaw. This last pair is perhaps the least essen- 
tial of any, but will often be found very convenient. 

Besides a good supply of forceps, each case should 
contain two elevators, and one gouge. 

All these instruments should be made of the best 
cast steel, and be of the most perfect spring temper, 


as this temper affords the greatest amount of strength 
with the same weight of metal, and an instrument 
that has a slight amount of elasticity not only breaks 
less easily, but takes something from the disagreeable 
shock produced by an entirely unyielding instrument, 
and is also, on that account, less liable to break the 
tooth to which it is applied. 

The first pair of straight forceps should be rather 
small, with delicate, evenly tapered, well-tempered 
blades ; their points finished down to sharp cutting 
edges, and slightly rounded or gouge-shaped, so that 
they can be readily and easily carried under the gum, 
cutting their own way quite to, or, if necessary, even 
beyond the edge of the alveolus. The general form 

Fig. 23. 

of the blades should be a segment of a somewhat 
conical cylinder ; and, as by a recurrence to the de- 
scription of the form of the roots of the single-rooted 
teeth, it will be observed that the outer portion of 
the root is larger than the inner, it will readily be 
seen, that in order that the forceps should fit the 
root correctly, one blade of the forceps should be the 



segment of a somewhat larger cylinder than the 
other. They should he as wide as the tooth to which 
they are applied will admit, allowing sufficient space 
for a slight rotary motion, without bringing the sides 
of the instrument in contact with the adjoining teeth. 
The importance of this is evident, from the plain 
fact that an instrument so narrow, or with jaws so 
nearly plain on their inner surfaces, that when applied 
they would bear on two small portions only of a 
tooth, which is in fact a cylinder, would readily 
crush it ; whereas, if the same tooth or root was en- 
circled, to a considerable extent, on two of its sides, 
it would J>ear almost any amount of force without 
being crushed ; and besides this, if an instrument so 
inclose a tooth, there is far less liability of its slip- 
ping, in giving the necessary rotary motion to rupture 
the membranes that confine it to its socket, than if 
seized by a smaller surface. But as the same class 
of teeth in different individuals vary materially in 
size, and as the central and lateral incisors and the 
/Cuspidati, in the same individual, always are of dif- 
ferent sizes, it is obvious that no one instrument, nor 
any two or three instruments, can thus accurately fit 
all the teeth to which they are to be applied ; but 
by carefully fitting one instrument to a tooth about 
the average, or a little above the average size, and 


another to one a little below that size, the two can 
be made to answer, very well, in all ordinary cases. 
Their blades, or jaws, should also be set so far 
apart at the joint, that when their ends have firmly 
grasped the neck of the tooth, they shall not impinge 
upon and crush their crowns ; nor in doing this, 
should the blades be much if at all curved, but they 
should rather approximate each other in direct lines 
from their joint to their points, otherwise they will 
act to some extent as excising forceps, and are there- 
fore liable to break the tooth, instead of extracting it. 

Fig. 24. 

The comparative length of the blades and handle 
of the instrument is also of some importance. If the 
blades are too short, in proportion, the leverage of 
the handles will be so great, that a sufficient amount 
of force to extract the tooth, will crush it ; and on 


the other hand, if the blades are too long, an extra 
amount of force beyond what is necessary to extract 
the tooth, will be required, by the grip of the hand, 
to prevent the instrument from slipping from the 
tooth, while, of course, the tractile force of either in- 
strument would be precisely the same, provided the 
entire length of each of the two instruments was the 
same. Therefore, a proper medium should be ob- 
served in this regard. This principle holds in rela- 
tion to all classes of forceps. What I would regard 
as about a fair proportion woulcl be, if the whole in- 
strument were seven inches in length, the jaws 
should be about from one inch and three-eighths to 
one inch and a half, measuring from the centre of 
the rivet. 

This size of straight forceps are to be used gen- 
erally for extracting the smaller central and the 

The next pair should be of similar form and con- 
struction to those just described, but wider, heavier, 
and stronger, and are to be used in the extraction of 
the cuspid ati and some of the larger and more firmly 
set central incisors. 

The third pair should also be rather heavy and 
strong, though not necessarily quite as heavy as the 
last described. They are a kind of semi-cutting for- 
ceps, intended especially for the removal of the roots 


of the incisors, cuspidati, and bicuspiclati, when one 
has been so unfortunate as to break one of these 
teeth in attempting to extract it. This is conmionly 
known as the Parmly forceps, and is a most useful 
and almost indispensable instrument. The blades of 
these forceps are shaped very nearly like a carpen- 
ter's " pod bit " or gimlet, with sharp cutting edges 
at their ends, and for about three-eighths of an inch 
along their sides ; and are hollowed out on their ap- 
proximal sides about as deep as the thickness of the 

Fig. 25. 

alveolar process, so that, when applied, they may 
fully cut through the process on each side, but with- 
out cutting the root of the tooth. 

Before applying this instrument, the gum should 
be slit along the course of the root to be removed, 
and dissected from the alveolar process, far enough 
to admit of its free and easy application. It is then 
applied over the process, on each side of the root, as 
far up as is deemed necessary, from an eighth to a 
fourth of an inch usually, when with one stroke of 
the forceps, the process on both sides is completely 


and smoothly cut through, and the root at the same 
moment firmly seized, which is then, of course, very 
easily removed, as its attachments are so nearly all 
cut away. 

There is no instrument that I have ever used with 
greater satisfaction than this. It does at one motion, 
smoothly, effectually and with greater ease to both 
patient and operator, till that can he done by tediously 
and roughly and painfully chipping away the alveo- 
lus with chisel and gouge and mallet, and after that 
the use of forceps, or punch, or turnkey, as is the 
habit of many. 

In selecting or having upper bicuspid forceps made, 
the same care should be observed in relation to their 
fitting the necks of the teeth on which they are in- 
tended to be used, without touching their crowns. 

Fig. 26. 

Xor should they bear upon the very end of the in- 
strument only, for if so, they do not hold the tooth 
firmly, and they act besides as cutting forceps. 
Their blades should, also, like the straight forceps, 


be cylindrical, so as to encircle so much of the tooth 
as is admissible, and the blade intended for the inner 
or lingual side of the tooth should be a little smaller 
than the other. The points of these forceps, too, 
should be sharp, so that they will pass readily under 
the gums, cutting their way, and not bruising it. 
Many of the forceps of this kind that are offered for 
sale are both too blunt and too much curved in their 
blades, so that they are bungling to apply, and when 
applied their bearing is too directly — too entirely — 
on their very points, m*aking them act either as cut- 
ting forceps, or else allowing their handles to rotate 

Fig. 27. 

on the points of the instrument, until the crown of 
the tooth impinges on one blade of the instrument, 
while the point of the other blade acts as a fulcrum 
over which to break off the tooth. Another com- 
mon objection to this kind of forceps is, that the 
blades are set at too great an angle to the handles, 


either for effectiveness or convenience. Indeed, for- 
ceps for these teeth made entirely straight, with the 
Hades a little narrower than the common incisor 
forceps, but enough thicker to give them their requi- 
site strength, and set enough further apart at the 
joint to clear the greater thickness of the crowns of 
these teeth, is quite as convenient as any other form. 
And as the same instrument is equally adapted to 
each side of the mouth, if both handles are made 
alike, it is more convenient than if one is bent to fit 
around the little finger. 

Great care should also be taken that the upper 
molar forceps — which must be rights and lefts — are 
well adapted to the class of teeth on which they are 
to be used, as well as to the hand. Their general 
form is so well established and known that a definite 
description can hardly be deemed necessary, or any 
suggestions on that head, further than that they are 
generally made more crooked than is either neces- 
sary or convenient, and as each forceps is always used 
for its own definite side of the mouth, they afford a 
firmer and securer hold for the hand if one handle is 
bent around the little finger, than if both are made 
straight. But as correct adaptation — accuracy of 
fit — of the instrument to the tooth, both for efficiency 
of action, and to avoid, as much as possible, the 
breaking of the teeth or other accidents, is a consid- 


eration of prime importance, I shall describe this 
part of it somewhat minutely. 

As the upper molar teeth have, almost uniformly, 
three roots, two external and one internal, it is evi- 
dent that, to fit the tooth accurately, the blades of 
the instrument must be of entirely different forms. 
Thus ; the internal blade must be a single concave or 

Fig. 28. 

crescent shape, and of the width of the neck of a 
medium-sized tooth of that class. The external 
blade, at its point, must be a double concave, with 
a point between, to fit into the bifurcation of the 
external roots. But, as these external roots are of 
unequal sizes, the anterior being larger and also more 



prominent than the other, so the grooves or concavi- 
ties in the blade of the instrument must he of differ- 
ent sizes to fit them ; the anterior groove being both 
larger and deeper than the posterior, otherwise the 
bearing of this blade will be only on the anterior 
root, and the point, intended for that purpose, cannot 
reach the bifurcation of the roots ; the result of which 
would be that the instrument is liable to slip alto- 
gether from the tooth or to glance off" against the 
posterior tooth, endangering it ; and even if it do not 
slip it is more liable to break the tooth than if it 
fitted it accurately. The relative difference in the 
size of these grooves should be about as three to two ; 
that is, the anterior groove should be about three- 
fifths, and the posterior about two-fifths of the width 
of the instrument ; and the anterior should be nearly 
or quite twice the depth of the other. The point 
should be distinct and prominent ; thick enough to 
give it strength, and turned slightly inwards, so that 
when once fairly applied to the bifurcation of the 
roots, there can be no possibility of its slipping ; or 
so that if necessary, as frequently happens, when the 
crown of the tooth has been broken off, it can be 
placed over the alveolus, piercing through it and 
taking hold in the bifurcation of the roots. 

The first and second upper molars are so nearly 
alike that an instrument well adapted to one will 


Fig. 29. 

answer equally well for the other. The roots of the 

upper wisdom teeth are so frequently close together 

or all condensed into one, and as 

they do not usually require much 

force to remove them, an instrument 

with a less prominent central point, 

or even one, hoth blades of which 

are a single concave, will often answer 


For the removal of the lower teeth, 
and their roots, as already intimated, 
four or at most five pairs of forceps 
are all that are necessary. One pair 
for the incisors and cuspidati, one 
for the bicuspidati, one for the re- 
moval of the roots of the teeth when 
it is necessary to remove a portion of 
the alveolus to get at them, and one 
pair for the first and second molars 
on both sides. Some, and perhaps 
most, operators use two pairs for the 
lower molars, rights and lefts, but 
one only is better. A small pair of 
lower root forceps, with very small 
blades, and the points of which come 
close together, will sometimes be found very con- 
venient for picking away loosened roots, or fragments 





of the alveolus, or fragments of teeth that may have 
been crushed in attempting to extract them; but 
although sometimes very convenient, they are not 
very essential. 

The only difference required between the forceps 
for extracting the lower incisors and the lower bicus- 
pidati is, that those for the incisors should be nar- 
rower in their blades than the others. Those made 
by Toland and Chevalier and some other makers, are 
tolerably well adapted to the purpose ; though I like 
them better more bent in their joints than they are 
usually made, as then when applied it brings their 
handles, and of course the hand, farther from the 
patient's face. I have mine represent an angle of 
something more than forty-five degrees. 

Fig. 30. 

The pair for the removal of the roots of such bi- 
cuspidati, or indeed of any other of the single-rooted 
lower teeth, the crowns of which have been broken 
off in attempting to extract, and are so firmly set, or 
broken so far below the edge of the alveolus, as to 
render it impossible or inconvenient to remove them 


with the elevator, or even tlie roots of the lower mo- 
lars, if broken below their bifurcation, was invented 
by myself in 1858. Their general form is the same 
as my ordinary lower bicuspid forceps, but having 
the pod-bit or gimlet-shaped blades, described for 
cutting the alveolar processes, and removing the 
roots, of such broken upper teeth; and is used in 
the same manner as that instrument, i. e., by first 

Fig. 31. 

dissecting away the gum, and inclosing a sufficient 
amount of both the processes and the root, within 
the jaws of the forceps; then cutting the process and 
removing the root at a single stroke ; which is effected 
so easily as often to surprise both patient and opera- 
tor. I find this, now, an indispensable instrument, 
and can hardly understand how I got on so long 
without it ; and am sure that no one who had once 
used it, would consent to be without it. 

The lower molar forceps, which are generally 
offered for sale, unlike those for the upper molars, 
which are generally too crooked for effectiveness or 



convenience, are usually too straight. Their beaks 
should be bent downwards, one blade above the other, 
at an angle of at least forty-five degrees from the 
line of their handles. They should have a bend at 
or just in front of the joint, so that when applied it 
shall throw the handles to the front of the mouth ; 
they should then have another bend, to bring the 
handles back nearly on a line parallel with the blades, 
for the nearer the handles and blades are to being on 
a line parallel to each other, so much the more di- 
rectly will the force applied to the handles act on 
the object grasped by the blades. 

The ends of the blades should each be formed into 
two grooves, or a double concave, to fit them accu- 
rately to the necks of these double-rooted teeth, and 
with a centre point to enter the bifurcation ; and 
these centre points should be made longer, more 
hooked, and more pointed than they are usually 
made, or than I have ever found them at any of the 
" dental depots," — a full fourth of an inch from the 
outside of the groove being quite short enough. The 
anterior roots of the lower molar teeth being larger 
and more prominent than the posterior, these grooves 
should be of a width and depth to correspond, i. <?., 
the anterior should be deeper and wider than the pos- 
terior. Forceps thus made, when fairly applied, seize 
the tooth firmly ; there is no danger of their slipping, 


and very little danger of ever breaking a tooth in 
attempting to extract. 

With an instrument thus shaped, the mere act of 
applying it is often sufficient to remove the tooth, 
for these long tapering points having fairly entered 

Fig. 32. 

the bifurcation, the upper side of each point, as it is 
further forced in, bears hard upward on the tooth, 
while the other bears as hard upon the edge of the 
alveolus, thus acting like two little wedges, and with 
sufficient force to raise the tooth from its socket, by 
simply closing the instrument upon the tooth. 

Another great advantage of this form of beak is, 
that when the crown of a tooth has been broken off 


above the bifurcation, that is, without separating its 
roots, the gum can be dissected from the alveolus for 
a short distance, and the instrument applied in the 
line of the bifurcation, and low enough down to 
secure its points entering there, when, with but a 
slight force upon its handles, the beaks will pierce 
the alveolus, firmly seizing the roots, when they may 
be easily and securely removed, and without any 
chipping or hacking of the alveolus, and in less time 
than it takes to describe the operation. 

These forceps, like all others, should have their 
blades wide enough apart, that, when firmly applied, 
the crown of the tooth shall be perfectly free, other- 
wise it will very likely be crushed or broken. 

I will here remark, en passant, that when only one 
pair of forceps is used for the teeth on both sides of 
the lower jaw — and it is much more convenient and 
effective than rights and lefts — i( should be the one 
made for the right side. 

Besides the forceps already described, it will some- 
times be found very convenient, for every one who 
extracts many teeth, to have one or two pairs with 
very narrow, but, at the same time, very strong 
blades, for extracting irregular teeth. Several very 
good patterns of this kind can be found in most of 
the principal dental depots. 

The forceps for extracting the deciduous teeth 


should have the same forms as the corresponding in- 
struments for adult teeth, hut of only about half 
their size. And such a set, consisting of ahout three 
instruments — that is for the molars — are very neces- 
sary. But I cannot refrain from remarking here, 
that these instruments should he used very sparingly, 
as great harm is done hy the indiscriminate extrac- 
tion of children's teeth. 

Of the elevators, one should he the common 
straight, spear-shape-headed elevator of the depots, 
modified and greatly improved by having its head 
about one-third smaller than they arc usually made, 

Fia. 33. 

Front view. 

Side view. 

or to be more particular in its description, it should 
be, in its entire length, about five and a half inches. 
The handle, the foundation of which should be a 
flattened continuation of the shaft, covered on cadi 
side with "nor)-, ebony, hardened rubber, or other 
suitable material, should be about three and a halt* 
inches in length, by about half an inch in width. 
The shaft should be gracefully tapered from the 


handle to the head, and about an inch and three- 
fourths in length. The head should he about one- 
fourth of an inch, or a little more, in length, and a 
fonrth of an inch, or a little less, in its greatest width, 
and tapered to a point. One side of the head should 
be flat, or very slightly concave, and the other side 
oval, and at its thickest part it should be nearly an 
eighth of an inch thick. The head of the instru- 
ment, regarding the flat surface as the front, should 
be bent backward, at an angle of fifteen or twenty 
degrees from the line of the shaft. This greatly 
facilitates its application, and adds much to its 

This instrument is sometimes very useful in ex- 
tracting roots of teeth, but more especially for ex- 
tracting the lower wisdom teeth. But, of its use, I 
shall speak more fully when treating of the extrac- 
tion of the wisdom teeth. 

The other elevator should be about five inches or 
a little less in length, including its handle, which 

Fig 34. 

should be about half the whole length of the instru- 
ment, round and well fitted t© the hand. Its blade 


should be about half an inch in length, and set at an 
angle of full forty-five degrees, from the line of its 
shaft. Its form and size should be that of the same 
length cut frOm one blade of a medium-sized common 
straight pair of forceps, the concave side front; its 
point sharp, and slightly rounded, or gouge-shaped. 

This instrument is used chiefly in the extraction of 
the roots of teeth, and is applied by placing the con- 
cave side of its point against the root to be removed, 
carrying it down perpendicularly, as far as practi- 
cable, between the root and its alveolus, then de- 
pressing the handle, llms using the edge of that pro- 
cess to some extent, as a fulcrum over which to pry 
out the root ; or else with an upward (if in the lower 
jaw, downward if in the upper) motion, push or 
force the root from its socket. 

This elevator is applicable to the roots of all classes 
of teeth, and is more serviceable in extracting roots 
than any other single instrument, or perhaps than 
all other instruments combined; and especially if 
they be vwy badly decayed and frail roots. Its 
sharp rounded point can readily be thrust some dis- 
tance between the l'oot of almost any tooth and its 
alveolus, at the same time rupturing to some extent, 
on one side at least, its articulating membrane, peri- 
osteum or peridenteum, as it is sometimes called, and 
seeming a good hold on the root, without danger of 


breaking or crushing it, with much less pain to the 
patient than the application of forceps, as it conies 
in contact with but one side of the root, and very 
rarely requires any lancing of the gum : all material 
advantages, both in its application and use, over 
either the forceps, or the elevators with serrated or 
bifurcated points, as they are most generally made. 
The gouge, of the extracting case, should be, in- 
cluding its handle, about six inches in length, three- 

Fig. 35. 

sixteenths of an inch in width, and shaped like the 
Turner's gouge. 

This is used for the removal of the roots of the 
teeth that are decayed or broken off so high up in 
their sockets as to be beyond the reach of the ele- 
vator. It is generally applicable only to the upper 
jaw. It is applied by passing it up the cell of the 
alveolus, until it reaches the root, and then carefully 
inserting its edge between it and the parietes of its 
cell, when, with a gentle pressure and a rotary 
motion of the instrument, the fragment of root is at 
once and easily removed, with very little trouble to 
the operator, and usually with but comparatively 
little pain to the patient. 


In this manner I have removed the point of a 
canine tooth, not more than three-sixteenths of an 
inch in length, and broken off full three-eighths of 
an inch above the edge of the alveolus, where no 
other instrument could possibly reach it, without 
first cutting away at least half an inch from the 
alveolus ; and, of course, involving a pretty severe 
wound in the contiguous soft parts. 

This is truly a very valuable little instrument ; and 
no extracting case should be considered fully equipped 
without it. 

Having described the necessary, and, as I think, 
the most appropriate and best instruments for ex- 
tracting all classes of teeth, and roots of teeth, in 
the easiest and best possible manner, that is, for re- 
moving every portion of a tooth, whether whole or 
m fragments, with the greatest facility to the opera- 
tor, and with the least pain, or other injury to the 
patient, we now come to a consideration of the mode 
of using them so as most effectually to attain these 

Sec. 2. Manner of Using Instruments. — As a pre- 
liminary I will remark, that proper success in ex- 
tracting teeth depends very much on the manner of 
the operator. He should, first of all, not only seem 
to be, but be calm and self-possessed ; and this state 



is to be attained in two ways; either by the ignorant 
recklessness of the charlatan, which cannot be too 
severely reprehended ; or by the confidence inspired 
by a definite knowledge of the parts to be operated 
on, and which is to be acquired only by study, obser- 
vation, and experience. Calmness and self-posses- 
sion in the operator is the readiest and most effec- 
tual means of securing the confidence of the patient ; 
and that, especially in all difficult cases, and with 
nervous, excitable patients — and most patients are 
apt to be a little nervous when about to have a tooth 
extracted — and with children, is a very important 

A patient who is excited, or lacks confidence in the 
operator, is far more likely to be restless, to start 
suddenly, to jerk about the head, to throw up the 
hands, and seize those of the operator, and thus break 
oft* teeth that otherwise need not and would not be 
broken, if calm and confident. 

Undue anxiety to operate, and to do it quickly, or 
apparent timidity, or want of confidence in his own 
skill and ability, excite suspicion and want of confi- 
dence on the part of the patient; while, on the other 
hand, a boisterous, blustering self-assurance may ex- 
cite disgust ; all of which operate sadly against the 
success and the reputation of the operator. 

I cannot here refrain from a few remarks on the 


treatment proper to be nsecl toward children when 
about to be subjected to the operation of having a 
tooth extracted. 

It is common, far too common, under such circum- 
stances, for both operators and friends, and even 
parents, to deceive children by telling them it will 
not hurt them to have their teeth extracted, or to 
tell them to " open their mouths so that the doctor 
can look at it, and that he is not going to do any- 
thing to it, or that he will not touch it, or that he 
will just put something on it, to make it well," and 
the like ; intended only to gain the confidence of the 
child, and then, covertly apply the forceps, and ex- 
tract the tooth before it has time to resist ; thus 
betraying that confidence and deceiving the child ! 
Sooner, by far, would I hold a child by force, and 
extract its tooth, than thus demoralize it, by teach- 
ing it such a lessson of untruthfulness, and so shaking 
its confidence in the integrity of its friends and of 
mankind. For myself I never allow any one thus to 
deceive a child in my presence, on whom I am about 
to operate, without the rebuke, at least, of at once 
correcting the impression ; and much less would I 
ever allow myself to commit such an act. Children 
reason as well as others, and if plainly and honestly 
told that the operation will hurt, but that it will 
probably hurt less than is anticipated, and that it is 


better even to endure severer pain for a moment, and 
be done with it, than to suffer for an indefinite time, 
and then be hurt quite as badly, and perhaps worse, 
than now, in having it out. Such persuasions, with 
kindness, will usually secure the consent of the little 
sufferer and retain his confidence and respect ; but, 
as already remarked, if reasoning and persuasion fail, 
it is far better to use force than deception. 

I will here further premise, that no one ought ever 
to attempt to extract any tooth, without first making 
a careful preliminary examination of the case. First, 
to satisfy himself whether the tooth ought to be ex- 

Patients suffering from toothache are very often 
deceived in relation to the tooth that causes the 
pain ; and then to extract the one that they might 
indicate without such examination, would be com- 
mitting a great fault, and an irreparable injury to 
the patient. Woful mistakes are, in this way, fre- 
quently committed, for which there can be no justi- 
fication. Patients often fancy, too, since artificial 
teeth have become so fashionable, that they ought 
to have even useful teeth taken out, and artificial 
ones inserted in their stead. This mistake ought 
not to be made, or at the least, judicious advice 
should always be given in all such cases. 

Secondly, after being satisfied of the necessity of 


the operation, the tooth to be extracted should be 
carefully examined in regard to its strength, its 
position, the firmness of its attachments, and the 
probable force that will be required for its removal ; 
the instrument or instruments most appropriate to 
be used ; and the best manner of using them. 

These preliminaries having been gone through 
with, the patient being seated in a slightly reclining 
position, suppose the tooth requiring extraction to 
be a superior central incisor, the common straight 
forceps, of the size and strength suited to the size 
and strength of the tooth, should be taken (no more 
instruments ever being displayed than are necessary 
for the proper performance of the operation in hand) ; 
then standing on the right side, and slightly in ad- 
vance of the patient ; the left arm closely surround- 
ing the patient's head, thus giving it a firm support ; 
the palm of the left hand resting on the patient's 
left cheek, and the fingers opening and protecting 
the lips ; apply the blades of the forceps over the 
tooth, with their points at the edge of the gum ; 
close them lightly upon the tooth, and then carry 
them up firmly and decidedly, till their progress is 
stopped by the edge of the^ alveolar process ; then 
close them firmly upon the neck of the tooth, and 
give one or two rotary motions, back and forth, suf- 
ficient in force and extent to sever the periosteum, 



when a slight tractile force will be sufficient to re- 
move the tooth. As the roots of these teeth are 
nearly, and sometimes quite round, the rotary motion 
ruptures their articulating membranes more readily 
than any other. 

I will here remark once for all, that all efforts at 
extracting this or any other class of teeth, should be 
made firmly and deliberately. All quick or jerking 
motions produce unnecessary shocks and alarm to 
the patient, and greatly endanger the breaking of 
the teeth ; especially if they are badly decayed and 
frail. A good rule in this regard is, never to move 
the hand faster than its effects can be followed and 
appreciated by the eye, so that it can at once be 
stayed, if it is perceived that undue injury is being 
inflicted, on any of the contiguous parts. " An 
operation is generally soon enough performed, that 
is well performed." 

For extracting the upper lateral incisors, and in- 
deed for all other teeth in the upper jaw, as well as 
all the teeth in the lower jaw, when forceps are used, 
except the incisors, cuspidatus, and bicuspidati on 
the left side of the lower jaw, the relative position of 
operator and patient should be essentially the same 
as for the extraction of the upper central incisors. 
The same forceps should generally be used, for the 
lateral as for the central incisors, but selected with 


reference to their adaptation to the width of the 
tooth ; and they should be applied in the same man- 
ner; but as the roots of these teeth are generally 
more or less flattened on their " approximal " sides, 
a motion forward and backward will frequently, if 
not generally, succeed better in severing their attach- 
ments than the rotary. 

The cuspidati for their removal require the use 
of the strongest straight forceps, which are to be ap- 
plied in the manner already described ; but as the 
roots of these teeth vary very much in their forms, 
sometimes being quite round and sometimes very 
much flattened, and as they are also frequently much 
curved, or even crooked, producing the effect, so far 
as the motions for extraction are concerned, of very 
broad roots, the appropriate motions, whether rotary 
or forward and backward, must depend on these cir- 
cumstances, and can generally be determined by a 
careful examination. But when an examination does 
not determine their form, it must be decided by trial ; 
and in such cases it is perhaps best, usually, to try 
the rotary motion first, and if that does not succeed, 
by a reasonable amount of force, then to try the 

The roots of these teeth usually being both larger 
and longer than those of the incisors, more force is 
generally required to remove them. 


For extracting the upper bicuspidati, the forceps 
described as suited to those teeth should be taken, 
and placed upon the tooth, whether it be in the right 
or left side of the mouth, with the longest blade of 
the instrument on the palate side of the tooth, and 
carried well up, quite to the alveolus ; and the motions 
should be very firm, steady, and gradual, first to and 
from the operator, in the direction across the mouth, 
and, when the attachments are- severed, a tractile 
force sufficient to remove it from its socket. These 
teeth, and especially without this care, are more liable 
to be broken, in attempting to extract them, than 
any other class, and more particularly the anterior 
one, which is so frequently divided into two slender 
roots, which makes its attachments stronger, in pro- 
portion to the strength of the tooth, than any other. 
But one other great reason, and probably the most 
common one, for their being so frequently broken, 
is, that the forceps generally in use for extracting 
these teeth are both too stiff and too much curved, 
in their blades, so that they do not yield, in the least, 
to the force applied to them, thus bringing all the 
power too suddenly upon the tooth, and also to bear 
too much upon their points, like cutting forceps, or 
the point of one of the blades acting as a fulcrum 
over which to break off the tooth by the handles 
being allowed to rotate upon it till the opposite blade 


comes in contact with the crown of the tooth, as 
noted in the description of this kind of forceps. 

In extracting the npper molars, and particularly 
the first/ and second, as they have each three roots — 
two external and one internal — two pairs of forceps 
are required, one pair for each side of the month ; 
the blades of which should be well fitted to the pecu- 
liar form of this class of teeth, as already described. 
They should be applied, like that for the bicuspidati, 
with the longest blade — the one having the single 
concave — on the inner or palate side of the tooth. 
This blade should be forced firmly to the edge of the 
alveolar process, and the central point of the outer, 
or double concave blade, should be forced under the 
edge of the process, so that it shall fairly enter the 
bifurcation of the external roots of the tooth, and 


Fig. 36. 

the edges of the concavities shall be in apposition 
with the edge of the process. The motions should 
then be forward and backward, to rupture the mem- 


branes, and then tractile. These teeth "being large 
and so firmly planted, require often a very considera- 
ble force for their removal ; but with snch an instru- 
ment so applied there will be no danger of its slipping, 
or but very little danger of breaking the tooth, or of 
failure of success. 

For the wisdom teeth in this jaw, the* forceps 
should be applied, as nearly as may be, in the same 
manner, and with great care ; but, from the size of 
these teeth, a smaller pair of forceps than the com- 
mon molar usually answer best. (I generally use my 
children's forceps for these teeth.) As the roots of 
these teeth are generally close together, and fre- 
quently all united, a small pair of forceps, of the same 
general form as the ordinary molar forceps, but hav- 
ing each blade with only a single concave, in a ma- 
jority of cases would be a better instrument.* When 
these teeth are curved, as they most commonly are, 
more or less — the face of the crown and the apex of 
the root both looking toward the cheek — the motion 
and force required are mostly, if not entirely, from 
within, or from the palatine side of the tooth out- 
ward. The force necessaiy for their removal is gen- 

* I have been latterly using Roberts's upper wisdom tooth for- 
ceps. At first sight they seem to be a queer, crooked, awkward 
kind of instrument ; such was my first impression of them ; but on 
trial I have found them most admirably adapted to the purpose 
for which they are intended. 


erally much less than for the preceding, or, indeed, 
than for any of the other teeth. 

The elevator is sometimes used for removing 1 these 
teethj and they can generally he very readily removed 
hy it, hut in so doing there is great danger of frac- 
turing the pterygoid process of the sphenoid bone. 
Therefore the use of the elevator cannnot be recom- 
mended for the extraction of these teeth. 

In extracting most of the teeth from the lower 
jaw, as already remarked, the position of the parties 
should be essentially the same as before described, 
but with these modifications : Instead of the palm of 
the operator's left hand resting on his patient's left 
cheek, the palm and last three fingers should firmly 
grasp the patient's chin, while the forefinger and 
thumb are to be used to remove and protect the lips 
and tongue. It will also be more convenient for the 
operator to be relatively more elevated, in relation 
to his patient, in operating on this jaw than on the 
upper, especially in extracting the molar teeth, as he 
will thus be in a position to exert more force, and to 
do it more directly. And for this purpose a small 
movable platform, or stool, of about six inches in 
height, will be found very convenient. 

Having assumed the proper position, if it be either 
of the incisors, the cuspidati, or the bicuspidati, that 
is to be extracted, take the instrument already de- 


scribed as suited to these teeth, place it upon the 
tooth with its longest or upper blade on its inner or 
lingual side, force both blades down firmly upon the 
edges of the alveolar process, and then with an inward 
and outward and an upward motion the tooth is usu- 
ally readily removed. 

In extracting the lower molar teeth from the right 
side of the mouth, the longer or tipper blade of the 
forceps (lower molar forceps) should be placed on the 
side of the tooth next to the tongue, care being used 
so to place them, and to force them down, that when 
closed their points shall fairly enter the bifurcation 
of the roots of the tooth ; then with a firm, steady 
motion forward and backward, across the mouth, and 
proper tractile force, the tooth is usually with cer- 
tainty removed. Sometimes, from the nature of the 

Fig. 37. 

case, this class of teeth require a great deal of force 

• for their removal, as where the roots at first diverge 

considerably, and afterward converge, till their points 


come in contact, inclosing, as they must, an amount 
of the alveolus which acts to all intents like a rivet, 
to hold the tooth in its socket, and which must nec- 
essarily be broken and brought away between the 
roots, or one or both of the roots must be broken. 
So, too, when the roots of such a tooth diverge in 
their whole length, till they are wider across their 
points than at the neck ; they not only require a great 
deal of force to start them from their sockets, but it 
must frequently be continued till their very points 
have left them. In such cases the roots must spring 
enough to clear them, or one of them must break. 
Such an accident, in such a case, is unavoidable, and 
should bring no reproach upon the operator. 

In extracting the lower molars from the left side 
of the mouth, the same instrument is used as for 
those on the right side, but the shorter or lower blade 
must then be placed on the inner side of the tooth, 
which necessarily brings a large portion of the instru- 
ment within the mouth. After it is applied, so that 
the points of the forceps fairly enter the bifurcation 
of the roots, the force is to be applied in the same 
manner as on the other side. The great advantages 
of using but one pair of forceps, for both sides of the 
mouth, in extracting these teeth are, that by stand- 
ing on the right side of his patient, the operator is 
in a much more favorable position to exert the nec- 



essary force ; and lie has also the full control of his 
patient's head, which he holds firmly and steadily "by 
encircling it with his left arm, which he cannot do if 
he stands in front of his patient, as he is obliged to 
do if he uses the right and left hand forceps. 

In extracting the incisors or cuspidati, and bicus- 
pidati of the left side of the lower jaw, it becomes 
necessary to stand as near directly in front of the 
patient as may be ; the chin of the patient grasped 
firmly with the operator's left hand, the fingers all 
being under the chin, while the thumb is within the 
mouth, and resting on the patient's other teeth. The 
instrument is then to be applied, and the force ex- 
erted in the same manner as in extracting the teeth 
on the other side ; that is to say, the blades must 
first be carried quite to the alveolus, and the move- 
ments of the instrument inward and outward. 

The roots of all the lower teeth are so much com- 
pressed or flattened laterally, that they do not admit 
of the rotary motion for their removal ; neither does 
the form of a suitable instrument readily admit of 
that kind of motion. The same remark may also 
be made in relation to the roots of the bicuspidati 
of the upper jaw. 

It will be observed that in my directions for the 
application of forceps, I have frequently repeated 
that they should be carried quite to, or even under 


the edge of the alveolar process. This I have done 
of design. I wish to impress the direction emphati- 
cally ; for where a tooth is seized by its crown, or 
just at the base of the crown, instead of at its neck, 
it is almost sure to be broken, and not extracted. 
This should ever be borne in mind, and never be for- 
gotten, whenever forceps are used, or in fact any 
other instrument. 

The wisdom teeth in the lower jaw are almost, if 
not quite, without exception, more or less curved or 
hook-shaped, thus forming nearly the segment of a 
circle, larger or smaller ; or sometimes the root stands 
at an angle little if any less than a right angle to its 
crown, and its apex or foramen always looking back- 
ward, or toward the ramus of the jaw. The crown 
of the tooth is short, and its neck very short. The 
tooth being in the posterior part of the mouth, the 
space between the jaws is frequently so small that 
it is difficult on that account fairly, or in any way 
conveniently to grasp it with the forceps, which dif- 
ficulty is also increased by its being so far from the 
front of the mouth ; and if grasped, from its position, 
it is difficult to bring the handles of the forceps into 
such a position as to act upon the tooth with any 
force without injuring the mouth with them. The 
jaw is here wide and flat on its top, with almost no 
alveolar process, so that the points of the forceps can 


but rarely, if ever, be inserted into the bifurcation of 
the roots of the tooth, — if indeed the roots are bifur- 
cated, and in a very large share of them they are not, 
— but can at most only seize the tooth on the two 
sharp points of the instrument (if the common for- 
ceps are used, and with any forceps), just at the base 
of its crown, where but a slight force is sure to break 
it off without removing its roots. It will readily be 
perceived by examination, that the shape and posi- 
tion of these teeth are such, that if the forceps could 
be ever so well applied, it would be almost impossi- 
ble with them to exert a force in the direction nec- 
essary to remove them easily. ; that is, in the direc- 
tion of the axis of the tooth, as from their being 
placed so far back in the mouth, the force of the 
forceps must almost necessarily be forward and out- 
ward or sidewise, one which must make the crown 
of the tooth operated on only impinge the more 
strongly against the crown of the second molar (if 
that tooth is still in its place), and the curved or 
hooked root incline to burst up the bone posterior 
to and above it, or if that be too strong to yield, to 
break the tooth ; whereas the force should be, readily 
to effect the object desired, directly upward and back- 
ward. Therefore, in removing this class of teeth, 
if the seeond molar is still in its place, I always use 
the straight elevator (modified as described) by in- 


serting its point firmly between the neck of the 
tooth to be removed and that of the segond molar, 
using that and the alveolus as a fulcrum over which 
to pry out the tooth. This, it is plain to see, exerts 
a force in the exact direction most directly to over- 
come all resistance ; or in other words, in that direc- 
tion that meets the least resistance, and that requires 
the least possible force to effect its removal. 

With this instrument, too, a lower wisdom tooth 
can quite readily be removed, when from abscess or 
other cause, the face is swelled, and the jaws closed 
to any extent short of absolute occlusion ; and I know 
of no other instrument that will effect the same re- 
sult under such circumstances. 

The position to be assumed when using this instru- 
ment, for extracting these teeth on the left side, 
should be the same as in using the forceps in extract- 
ing the left lower incisors. On the right side, the 
same as for using the forceps on that side. 

If the second molar has already been removed, the 
straight elevator cannot be used, there being nothing 
left for a fulcrum over which to use it. But in such 
cases the other kind of elevator may sometimes be 
used with good effect, treating the tooth as if it were 
simply a root. The forceps, too, can better be ap- 
plied and used now, than when the second molar 



was in its place. But the means must be adapted 
to the emergencies of the case. 

As, in describing our instruments and the purposes 
to which they are applied, we have already, and 
almost necessarily, described the method of extract- 
ing the roots of teeth whose crowns are gone, and 
as we shall have need to refer to that subject again 
to some extent when treating of accidents which are 
liable to occur in the operation of extraction, nothing 
further need be here said on this subject. 

With the necessary anatomical knowledge, and 
sufficient experience to acquire self-confidence, with 
the instruments here described, and those instru- 
ments used as here directed, but little difficulty need 
ever be apprehended in the extraction of almost any 
tooth. True, some extraordinary cases will require 
extraordinary means, for which the operator must, 
to a great extent, rely on his own judgment, guided 
by the exigencies of the case. 



" Lancing the gums," in some cases of extraction, 
is a very important preliminary operation, and, 
when required, it should be done well and thorough- 
ly. A description of the manner of doing it has 
already been incidentally given, when explaining 
the method of extracting the teeth, or rather, the 
crownless roots of teeth, which require it ; to wit, the 
roots of such teeth as are broken off so far below 
the gum and edge of the alveolus, that they cannot 
be seized or apprehended by the instrument to be 
used for their removal, without either cutting or 
injuring the gums ; or such roots of teeth as, from 
inflammation or otherwise, have the surrounding 
gums more or less closed over them, rendering it 
difficult to apply any instrument without first re- 
moving the gum, or at least not without inflicting 
a great deal more pain, with the extracting instru- 
ment, than with the knife. The manner, and the 
amount of cutting, will, of course, depend on the 
circumstances of the case. If it be a firm root, bro- 


ken low, so that to remove it, it is necessary to re- 
move a portion of the alveolus, the gum should be 
dissected by one or two strokes of the knife from 
the alveolus, as deep as the forceps are to be applied, 
and as wide as is necessary to facilitate their appli- 
cation ; another cut should also be made by a single 
stroke of the knife in the direction of the length of 
the root, forming two small flaps of the dissected 
gum. The same operation should be performed on 
both the inner and outer sides of the root if forceps 
are to be used ; but if the case is one where the ele- 
vator is to be used, it will only be necessary to make 
the cuts on the outside, and usually in but one di- 

In performing the operation, any of the curious 
and even complicated lancets on which so much ex- 
uberant ingenuity and skill have been expended, can 
perhaps, with care, be made to answer the purpose as 
well, or nearly as well, as a simpler and more conve- 
nient one ; and a plain bistoury or a scalpel, or a com- 
mon penknife, will answer just as well. 

Although, as I have said, this operation is some- 
times necessary, and, in some cases, quite important, 
yet, as a general rule, it ought to be entirely omitted ; 
and for various reasons. The first of which is, that 
in all ordinary cases, and with but very rare ex- 
ceptions — that is to say, in the extraction of all 


entire teeth, and most roots of teeth — it is entirely 

The resistance to be overcome, in extracting most 
teeth, is offered chiefly by the strength of the firm, 
dense membrane uniting their roots to their alveoli. 
It is therefore very evident that simply severing the 
gum from the neck of the tooth, to which it is usu- 
ally not strongly attached, and all of it that can be 
reached by any ordinary gum-lancet being of but 
small extent, can have but little influence in lessening 
the amount of force that it would require to extract 
them. A knife or gum-lancet of any kind, cannot, 
by any possibility, be carried far enough between the 
tooth and its alveolar process, to sever but a very 
small portion of the periosteum ; and it is very seldom 
that any one ever attempts to cut this membrane 
below the edge of the alveolus, unless it may be in the 
case of some loosened root which he intends to remove 
entirely with his knife. 

The next great source of resistance in this opera- 
tion, and sometimes — not unfrequently — the source 
of greatest resistance, is the divergence or converg- 
ence of their roots ; or the divergence of them for a 
portion of their length and their convergence the 
balance, requiring, if one or more of the roots do not 
first break, the removal of the bony septum between 
their roots, or the yielding of the parietes of the alve- 


olar cells, or tlie springing of one or more of the roots, 
to admit of their removal, even if the periosteum 
were all scraped or macerated away. 

Corrugations in the roots, or crooks in them, exert 
a similar influence which no knife or lancet, however 
ingenious its form, can overcome. 

As already remarked, the attachment of the gum 
to the neck of a tooth is always slight, and the ex- 
tent inconsiderable ; so slight and so inconsiderable, 
that no operator or patient could possibly appreciate 
the difference in the amount of force required, or the 
pain experienced, whether the gums were cut or not. 
And besides this, the lancet in almost all cases is 
rendered entirely unnecessary by the fact that prop- 
erly constructed forceps — forceps fitted to each class 
of teeth on which they are to be applied, as described 
in the preceding chapter — will more easily and more 
thoroughly do it, and by the same movement that 
applies them to the tooth, than any lancet can be 
made to do it ; and with no more pain, if even as 
much, in the application, than if the gum had been 
ever so freely lanced before. 

The operation of lancing the gum preliminary to 
extracting a tooth is, in most cases, not only unnec- 
essary, but decidedly objectionable for many reasons. 

It produces a great deal of unnecessary pain. With 
many patients, the dread of having the gums lanced 


is greater than that of having the tooth extracted. 
Many timid and nervons patients can, by great effort, 
bring themselves to bear the infliction of one pain, 
bnt cannot a second. So, it is no uncommon thing 
for such a one to submit to having a gum lanced, 
and then to go away without having the tooth ex- 
tracted ; but who would gladly have had it out, if it 
could have been done at once ; as it should have been. 

There is also some more danger from excessive 
hemorrhage when the gums are lanced than when 
they are not. A smoothly cut surface is more liable 
to bleed than a lacerated one. Therefore, in all cases, 
when it is necessary to extract a tooth, where a hem- 
orrhagic diathesis is known to exist, or is mistrusted, 
the use of the lancet should be most sedulously 
avoided. I once knew a child to bleed to death, in 
the hands of a very able surgeon, from simply cutting 
the child's gums to facilitate the eruption of its upper 
deciduous central incisors, though all known means 
were resorted to to arrest the bleeding, from simple 
and long-continued pressure, through all the range 
of styptics and astringents, from cold water to the 
actual cautery. 

The only argument known to me in favor of the 
general use of the lancet is, that by the adhesion of 
the gum to the neck of the tooth, sometimes the gum 
may be lacerated before that adhesion yields. If 


this were the usual result of neglecting to use the 
lancet, or if it were even a frequent occurrence, in 
consequence of such neglect, there would he force in 
the argument. But as that accident, in my experi- 
ence and observation, does not occur more than once 
in some thousands of times, and even then is the re- 
sult of other carelessness — the good rule not being 
observed of operating no faster than the eye can 
follow, or than the hand can be stayed at any 
stage of the operation, and, as already demonstrated, 
the forceps accomplish the object more effectually, 
without loss of time to the operator, with less pain, 
and without the interval of terrible suspense to the 
patient'; therefore, on the principle of "the greatest 
good to the greatest number," I cannot think it justi- 
fiable to torture the great multitude, in order to save 
an individual, or even a few persons, from the possi- 
bly unnecessary slight infliction of pain that might 
thereby have been avoided. 

Have a gum-lancet, then ; let it be a good, plain, 
practicable instrument, but use it seldom. 



SEp. 1. Although with the present improved styles 
and new kinds of extracting instruments, and the 
improved manner of using them, accidents from 
this operation are much less frequent than formerly, 
still they will sometimes occur, even with the best 
informed and in the most skilful and careful hands, 
and frequently from no want of care or precaution 
on the part of the operator. 

These accidents may occur from undue excite- 
ment and uncontrollable restlessness on the part of 
the patient ; from malformation or mal-arrangement 
of the teeth ; from some peculiar temporary condi- 
tion, or from some inherent vice in the constitution 
of the patient ; and sometimes they may occur from 

Among the most serious of these casualties, though 
fortunately far from being the most frequent, is ex- 
cessive hemorrhage. 

This, though sometimes the result of other causes, 


as the accidental fracture of the alveolus, by which 
the dental artery may have been wounded, or by an 
extensive laceration of the gums, is more commonly 
dependent on some morbid state of the system, tem- 
porarily changing the character of the blood, so that 
coagulation does not readily occur; or producing 
such relaxation as to overcome the contractile power 
of the bloodvessels ; or it may depend upon a consti- 
tutional hemorrhagic diathesis, — circumstances that 
cannot always be foreseen, or if foreseen, are not 
always within the control of the operator. 

If a hemorrhagic diathesis is known to exist in 
the patient, or in any of his family, and an operation 
becomes imperative, the utmost care should be used 
to avoid all incisions, lacerations, or other wounds 
that are not absolutely unavoidable, and especially 
in such cases should the use of the lancet be avoided. 
" A clean cut bleeds more freely than a lacerated 

Dr. Taft, in his " Operative Dentistry," page 356, 
relates a case of a patient who very nearly lost his 
life by hemorrhage, from simply lancing his gums, 
preparatory to extracting a tooth, which he finally 
refused to have extracted. And I have already re- 
ferred to a case which came under my own observa- 
tion, of an infant which bled to death from only a 
comparatively slight incision of its gums. 


If there be good cause to apprehend excessive 
bleeding from an enfeebled condition of the system, 
or from any other cause, and the nature of the case 
will admit of delay, a proper course of tonic treat- 
ment, would, no doubt, be but a prudent precaution 
before proceeding to operate. But, unfortunately, 
in most cases, the liability to this accident cannot 
be foretold nor foreseen, therefore, when it does 
occur, our only recourse is to make the best repara- 
tion in our power, by taking advantage of all favor- 
able circumstances, and by availing ourselves of the 
best means known for arresting the flow of blood. 

The most common recourse in such cases is the 
application of cold water, or of some of the various 
astringents* and styptics, or of compresses, or a com- 
bination of some or of all of these agents. 

Of the styptics and astringents, which have been 
extensively used in such cases, and with varying 
success, the most common and effectual are tincture 
of nut-galls, powdered nut-galls, tannic acid, gallic 
acid, tincture of matico, the leaf of the matico rolled 
and inserted, oil of turpentine, nitrate of silver, spi- 
ders' web, and perchloride of iron, persulphate of 
iron, and some have resorted to the actual cautery, 
but that, I think, is always an operation of doubtful 
expediency. From my own observations of this 
searing process, which, however, has not been very 


extensive, its only effect is to form a crust or scab 
on the surface, which may temporarily arrest the 
flow of blood, but without any tendency to the for- 
mation of clot in the blood, or any permanent con- 
traction of the vessels, and which is generally soon 
forced off by the action of the blood, leaving a larger 
bleeding surface than before, to be treated by other 
means. The milder means are generally more effec- 
tive, and the after consequences far less serious. 
Sometimes, when the bleeding is quite persistent and 
very considerable, simply rinsing the mouth with 
a pretty strong solution of tannin, or of powdered 
nut-galls, is sufficient to arrest the bleeding, especi- 
ally if it proceeds from the capillary vessels ; but a 
more effectual way is to saturate pledget's of lint or 
of cotton in a solution or tincture of these substances, 
and having first cleared the sockets from which the 
tooth has been removed, as well as may be, of all 
clots and blood, thrust them to the bottom of the 
bleeding cells with a probe, or other convenient in- 
strument, and so keep on, adding pledget after 
pledget, till the cell is full. "When matico or turpen- 
tine is used it should be done in the same manner. 
Sometimes it may be more convenient to use the 
tannin or galls in powder than in solution or tincture ; 
then the pledgets may be moistened in cold water, 
and rolled in the powder until it has taken up all it 


will contain, when the pledgets are to be packed 
into the bleeding cells as before described. When 
nitrate of silver is used, the most effectual way is to 
powder the salt and apply in that manner. 

If thus packing the cells does not prove sufficient-, 
a few folds of lint or of common muslin may be placed 
above it, and over all place a metallic plate with 
clasps, or a bit of wire twisted together, so that its 

Fig. 38. 

ends may form clasps to attach it to the adjoining 
teeth ; but for the want of such conveniences, or if 
there are no teeth adjoining, a cork may be cut, so 
as to leave one end of it the shape of the letter V, 
and placed over the compress and retained in place, 
and made to produce pressure by closing the jaws 
upon it, and keeping them closed, by passing a band- 
age over the head and under the chin ; or the same 
thing may be effected by placing enough folds of the 
muslin above the bleeding part to meet the teeth or 
gums of the opposing jaw, when the mouth is to be 
closed, and the bandage applied as before described. 
When the pressure can be sustained by clasping to 
other teeth, it is to be preferred to bandaging, as it 
is much more comfortable to the patient, as this 
leaves the jaws entirely unrestrained. 



When such means are necessary as the bandaging 
together of the jaws, or the use of metallic plates or 
wires to produce pressure, they should be allowed to 
remain, and to sustain a steady pressure for several 
hours after the bleeding has ceased, and the pledgets 
with which the sockets have been filled, and more 
especially if there be a distinctly marked hemorrhagic 
diathesis, should be allowed to remain till the pro- 
cess of suppuration and granulation has removed, or 
at least loosened them ; and when removed, it should 
be done with great care and delicacy. 

If the case be urgent, and the above-named reme- 
dies are not at hand, or do not effect the desired re- 
sult, there is another article which is almost every- 
where to be found, which may be tried, and which 
in my hands once answered a most admirable purpose. 
This article is the common spider's web, or " cob- 
web." The only objection or inconvenience that I 
know of to the use of this article is, that my patient 
complained of pretty severe temporary pain from its 
application. In illustration of its effects I will re- 
late a case : . 

On a bitterly cold Saturday evening, in the winter 
of 1855, at about eight o'clock, a young woman of 
apparently about twenty years of age, of fully me- 
dium height, rather incliued to embonpoint, though 
not decidedly so, of graceful form, with a pleasant 


face and manner, and a complexion that, by gaslight, 
seemed very fair, but which, by daylight, assumed 
a rather sallow, unhealthy kind of hue, came to my 
office, accompanied by a friend, and wished me to 
extract her first right lower molar tooth. After ex- 
amination, I applied my forceps, and removed it, and 
with considerably less than the average amount of 
force required in such cases. She expressed herself 
delighted at the ease with which I had taken it out, 
and was about to leave, but noticing that blood was 
flowing more freely than is usual after the extraction 
of a tooth, I suggested that she had better wait till 
the bleeding had ceased. After waiting for a con- 
siderable length of time — she rinsing her mouth freely 
with cold water meanwhile — and, seeing no abate- 
ment in the bleeding, I added tannin to the water, 
but with no effect. I then plugged the alveolar cells 
with pledgets of cotton, previously moistened and 
rolled in tannin. This seemed to check the bleed- 
ing for a very short time, but did not entirely stop it 
even for a moment. I next applied pledgets of 
cotton, saturated with oil of turpentine, and after 
that with tincture of matico, but each with no more 
favorable result. I then resorted to nitrate of silver, 
which I applied by moistening pledgets of cotton and 
rolling them in the pulverized salt until they had 
taken up all they would contain, and with them 


firmly plugged the cells. To my great delight, after 
this application, the bleeding stopped, and my patient 
left my office about an hour and a half after the tooth 
was extracted. 

While she was in my office I learned from her and 
her female friend who accompanied her there, and 
from others subsequently, that she was stopping with 
an irregular medical practitioner, for the purpose of 
being with and nursing a younger brother, who was 
there to be treated for some scrofulous affection, and 
to be herself treated for leucorrhcea, or some other 
uterine difficulty, and was at the same time acting 
as a kind of sub-housekeeper for her medical adviser, 
a female physician. 

The next day, passing the doctress's (?) office, and 
feeling a great deal of anxiety about my patient of 
the night before, I called to inquire about her, and 
was told that my application had only restrained the 
hemorrhage for a few hours, and that she (the madam 
doctor) had stopped it by the application of " the 
scrapings of sole-leather." . Although I could not 
readily understand why the comparatively little tan- 
nin contained in the leather should have so much 
more effect than the pure tannin, which I had used, 
I was very glad to learn that the bleeding had been 
stopped, and by any means or by any hands. 

On the Tuesday afternoon following a messenger 


came, desiring me to come and see my patient as 
soon as possible, saying that she was again bleeding 

Having already tried most of the well-known pow- 
erful styptics in her case (the perchloride of iron had 
not then been brought into notice), and knowing that 
the "cobweb" had a very general popular reputa- 
tion for arresting hemorrhage, I provided myself 
with that article before going to see my patient ; 
whom, when I went, I found lying in bed, with her 
head over its side, and bleeding badly ; and she said 
she believed she was bleeding to death, and in that 
opinion there seemed grave reasons for concurring. 

First of all I directed her to assume a position as 
near erect as possible consistent with a sitting pos- 
ture. I then cleansed out the alveolar cells as well 
as I could, and plugged them with the cobweb ; and 
to my great gratification, found the bleeding was 
stopped by it immediately. 

On examining my patient, I found all her extremi- 
ties almost deathly cold, her face flushed, and her 
head hot. I ordered a hot pediluvium, to which, 
should be added a large quantity of ground mustard, 
and waited to see the faithful administration of it, 
and that her feet were afterwards thoroughly rubbed 
and dried with coarse towels, thus doing all I conld 
to equalize her circulation. I then directed her to 


take care to keep her extremities warm; to keep 
"herself quiet ; to avoid all excitement and exertion 
(that morning she had been exerting herself unusu- 
ally in her domestic affairs) ; and to send to me im- 
mediately on any recurrence of the bleeding. 

I did not see her again, but had a message some 
days after, that she had had no return of the hemor- 

From my success in that case, I would most 
strongly recommend — as strongly as I could from 
the experience of any single case — a trial of the cob- 
web in any case of intractable alveolar hemorrhage. 
It is always and everywhere attainable, and easy of 
application ; and although at the time of my trying 
it I was not aware that it had been used in such 
cases, I have since learned that others have used- it 
with marked success in similar cases, after having 
failed with all other available remedies. 

The only other case of alveolar hemorrhage that 
has ever given me any great degree of anxiety, out 
of a great many that have required some treatment 
to arrest an undue flow of blood, occurred in the 
autumn of 1847. This, also, I will relate, in explan- 
ation of the general plan and effect of treatment in 
such cases. The. patient was a man of about twenty- 
eight or thirty years of age, about medium height ; 
of rather a spare habit; of active movements, and 


what, by phrenologists, would probably be called a 
nervous temperament, and by occupation a book- 

The operation was the extraction of the root of a 
lower bicuspid. It was broken, or rather decayed 
away, quite to the gum, but still very firm in its 
socket, and it gave me some trouble to remove it ; 
but I succeeded finally, and very much to the satis- 
faction of my patient, and without any material lac- 
eration or injury to the gums ; neither was there any 
unusual degree of bleeding, either in time or quan- 
tity ; but, about six days afterwards, he returned to 
me bleeding most profusely, and said that he had 
been so bleeding for four or five hours. I cleaned 
out the socket, from Whence the root had been re- 
moved, and plugged it with pledgets of cotton, pre- 
viously moistened with water and rolled in pulverized 
nut-galls, over which I placed a silver plate, confined 
to its place by clasping the contiguous teeth ; thereby 
securing steady and constant pressure. This arrested 
the bleeding for the time, and my patient went away, 
but in a few hours he returned bleeding as profusely 
as before. I then substituted pulverized nitrate of 
silver for the galls, and applied my compress as be- 
fore, and with more satisfactory results, for it stop- 
ped the bleeding for the time, and in an hour or two 
afterwards I saw him on a stage-coach, having started 


with his family to visit some friends in the country. 
As there was still a very slight oozing of blood, I felt 
considerable apprehension at seeing him go away 
from any immediate reach, but as I thought the 
change of air might be of service to him, and as 
I did not wish unnecessarily to alarm either him 
or his family, by expressing my fears, I thought it 
not best to oppose his going. On his return, two or 
three weeks afterwards, he told me that the blood 
continued to ooze a little for an hour or two and 
then ceased ; after which he had no further trouble 
from it. 

Although the local treatment here indicated will 
claim our first, and perhaps chief attention, the state 
of the circulation and the general condition of the 
system must not be overlooked. In some cases, our 
hope of success must greatly depend on equalizing 
the circulation, and in such internal remedies as are 
known to give tenacity to the system, to increase 
the fibrine of the blood, and restore its quality of 

Sec. 2. Breaking; the tooth is one of the most 
common accidents attendant upon attempting to ex- 
tract it. 

This may depend upon many circumstances, and 
may occur in any part of the tooth. With the use 


of the key this is a very common occurrence, and 
then occurs most commonly at their necks. In such 
cases the most certain way of avoiding this occur- 
rence is by avoiding the use of the key ! 

In using the forceps, too, it may occur at that 
point ; but when it does, it is, most commonly, by 
the use of a badly constructed, or by the bad appli- 
cation of a good instrument ; as explained when 
describing the proper application and use of the for- 
ceps. But again, this accident may occur with the 
best instruments, and in the most skilful hands, as 
when the tooth is so much decayed, or from other 
causes is so frail or brittle, as not to be able to sus- 
tain the pressure of the instrument required for its 
removal ; or the patient may suddenly seize the hand 
of the operator, and partially displace the forceps, or 
exert a force upon it beyond what is required, thus 
crushing it, or by exerting a force in a wrong direc- 
tion, and beyond the control- of the operator. 

The roots of some teeth are so much curved, 
either outward or inward, as ulready noticed, or 
sometimes forming absolute hooks, that they cannot 
be removed entire, without, at the same time, re- 
moving a portion of the alveolar process ; but in such 
cases the root is more likely to break than the pro- 
cess to give way. And as the crown of a tooth does 
not indicate the form of its roots, we can take no 




extra precautionary means to avoid the accident, 
and, even if they did ever so clearly indicate their 
form, we should be no better off. 

When this accident occurs, the proper after-treat- 
ment will depend very much on the condition of the 
tooth, and the place of the fracture. 

Fig. 39. 

If the periosteum of the roots of such a tooth is 
inflamed, or if they are the cause of abscess, the 
most strenuous and persevering efforts, if necessary, 
should be resorted to for their entire removal. And 
the forceps for excising the alveolus, the elevator, 


or the gouge, may be resorted to, as the case may re- 

If th£ tooth be an upper molar, broken at its neck 
so that its roots are left attached together, the gum 
should be dissected from the alveolus sufficiently to 
allow the forceps to be readily applied a line or two 
above the edge of the process, which, with forceps 
such as described, will usually afford sufficient hold 
tg remove them. But if the common molar forceps 
cannot be made to effect the object, another kind of 
forceps, with its external blade somewhat more ex- 
tended, more curved, and more attenuated, in short, 
constituting a simple hook, to be applied somewhat 
higher up in the bifurcation of the buccal roots, 
while its inner blade is like that of the common for- 
ceps, which is to be applied either to the palatine 
root or over the alveolus, will sometimes be found 
very useful. This, however, need but very rarely 
be resorted to, if the regular molar forceps are con- 
structed as described. 

If a lower molar is broken above the bifurcation, 
the common lower molar forceps (having sharp 
curved points as described) should be applied, with 
their points on a line with the separation of the roots 
outside of the alveolus, taking care first to dissect 
away the gum on both sides, so as to avoid lacerat- 
ing or otherwise inj uring it ; closing the forceps 


through the alveolus, and thus firmly seizing the 
roots and bringing away a small portion of the pro- 
cess with them. Sometimes, when the roots are very 
firmly set in the jaw, and there are indications that 
they cannot he brought away together, without injury 
to the jaw, it may be advisable to use the splitting 
forceps to separate them, when they may be brought 

Fig. 40. 

away singly, either with the elevator, or the* forceps 
which cut the alveolus and seize the root. Some- 
times they will be so much loosened in the act of 
splitting them apart, that they can be very readily 
picked away with lower root forceps. 

If the broken tooth be a single-rooted one, and it 
cannot be removed by the elevator, then the forceps 
for cutting the alveolus should be used. Lower 
molars broken below their bifurcation, should be 
treated in the same manner. 

If the root of the tooth be broken and is sound and 
healthy, and not already loosened, and not more 
than three-fourths of its length remain in the jaw, 
and sometimes if even more than that remain, my 



practice is to let it remain ; knowing that before it 
is likely to produce further trouble, its hooked point 
will have been absorbed, the alveolus also so much 
absorbed, and the whole root so far thrown up in its 
socket, by that process of nature which always strives 
to relieve herself of all useless or effete parts, that 
it can readily be apprehended and removed, by the 
elevator or the root forceps, and w T ith comparatively 
little pain to the patient or trouble to myself. But 
in such cases I am always careful to explain the 
circumstances to my patient, that he shall have no 
occasion afterward to tell me, or others, that I de- 
ceived him. 

It is a fortunate circumstance, too, that sound and 
healthy roots are much more liable to be broken and 
left in the jaw than diseased ones ; and from the fact 
that if abscess or inflammation have supervened, the 
bony socket has already, to some extent, at least, 
given place to the accumulation of pus, or to the 
thickened membrane, and thus left the root more or 
less loosened in its sockets. 

Sec. 3. Laceration of the gums, with such bruises 
as sometimes produce severe inflammation, and even 
sloughing, is by no means a very uncommon accident 
where the turn-key is in general use. To avoid its 



frequent occurrence, as well as the occurrence of 
many other accidents, avoid the use of the key. 

This accident rarely occurs, when forceps are used, 
except where the alveolar process, hy being very thin, 
and very strongly attached to the tooth, is broken 
and brought away in the operation. In such cases, 
by the attachment of the gum to the alveolus, unless 
great care is used, pretty severe wounds may be in- 
flicted. But the ordinary lancing of the gum is no 
safeguard against its occurrence. In some very rare 
cases, too, the gum may be so strongly attached to 
the neck of the tooth, at the back part of the wisdom 
tooth, where the forceps or whatever other instru- 
ment is used, cannot come in contact with it to effect 
its separation, as to produce slight laceration before 
the attachment yields. 

The proper way to avoid this accident, in either 
case, is carefully to watch the operation, and never 
to operate so rapidly, or so roughly, as not to be able 
to stop before any serious injury has been inflicted. 
Thus, when the tooth has been started from its 
socket, and it is perceived that the alveolus is broken, 
and does not readily part from the gum, or if the 
gum adheres to the neck of the tooth, suspend its 
removal, and dissect away the gum from the bone, 
or from the tooth when the operation can be con- 
cluded without injury. 


I have oftener seen a strip of gum torn up, and 
even for a considerable distance across the roof of the 
mouth, in attempting to extract the root of a tooth 
with root forceps, whose points, when closed, nearly 
or quite touched each other, and after the gums had 
been lanced, in the blood mistaking the edge of the 
gum for the root, seizing upon it, and pulling away 
suddenly, and thus tearing the gum, than by any ad- 
hesion to the neck of the tooth I Due care will, of 
course, avoid such an accident as that. 

If by any means the gum is unfortunately torn, 
so as to leave any loose flaps or shreds, they should 
be carefully cut away ; and for this purpose scissors 
are generally most convenient. 

Further treatment, beyond simply rinsing the 
mouth freely with cold water, if it feel hot and un- 
comfortable, will rarely be necessary, unless there 
happen to be a predisposition to hemorrhage, or to 
inflammation, when it may prove troublesome, like 
any other wound ; and will require to be treated by 
general principles, modified by the existing circum- 

Sec. 4. Fradureof the Alveolus. — This accident, too, 
at least to such an extent as to be of any consid- 
erable consequence, most frequently occurs from 
the use of the key ; and therefore requires us again 
unwillingly to speak of that instrument of torture, 


which, if we did not know was still very extensively 
in use, not only in the country, but in the cities, and 
even by dentists as well as by physicians, we would 
not so much as once have alluded to it. 

Xot ^infrequently, with this instrument, where the 
fulcrum is allowed to rest too low upon the gum, or 
too high, according as the case may be in the lower 
or the upper jaw, the side of the alveolar process is 
wrenched away to the extent of the width of the 
tooth, and the whole length of its roots, and some- 
times to the extent of several teeth, thus depriving 
theuuof their support, and ultimately involving their 
loss, and the direct and permanent disfiguration of 
the sufferer. To avoid such accidents, I must say 
again, avoid the use of the key. 

It is true that this accident may, and even must to 
a limited extent occur, by the use of the best and 
most carefully used forceps ; but never to anything 
like the extent that is common in the use of the key. 
For example, in the removal of a tooth whose roots 
converge so as to inclose the septum of bone between 
•them, this portion of bone must come away with the 
tooth, that is, if the tooth comes away entire ; but 
this, except as it sometimes requires a great deal of 
force to remove a tooth so situated, is of no conse- 
quence, and is hardly entitled to the designation of 
an accident. £o, too, if the roots of a tooth are so 


greatly divergent that they cannot otherwise he 
drawn, a portion of the alveolar process may he 
cracked and forced away, or may he hroken and 
brought away with the tooth. And sometimes, a 
very long single root, especially if it -happen to he 
crooked, or of an uneven or corrugated surface, and 
its alveolus chance to be unusually thin, as is the case 
sometimes with the upper canine teeth, and more 
frequently than with any other class, in which cases 
the periosteal attachment may prove stronger than 
the alveolus, and a portion of it, and sometimes a 
pretty large portion of it, may he brought away. In 
such cases, however, the fault is not in the instru- 
ment, or necessarily in its application, or manner of 
using, hut in the circumstances of the case. Then, 
if an accident so occurs, we can only do our best to 
retrieve and to excuse it. 

Although the operator may know that such an 
accident may not be of the least consequence, and 
sometimes even an advantage rather than an injury, 
it is not always easy to convince his patient of that 
fact ; and as such occurrences, however trivial they 
may be, are very apt to -create distrust in the mind 
of the patient, as to the skill and ability of the oper- 
ator, and sometimes even to affect his standing and 
usefulness, when it can be clone by quietly cleaving 
the fragment of bone from the tooth, and putting it 


aside, it is perfectly justifiable and right for him 
to keep the knowledge of the fact to himself. This 
is at least safer for his reputation than to make a 
display of the case, to show the great difficulties he 
has had to overcome. 

Although I would observe a judicious caution in 
such cases, I would not compromise my conscience 
by a denial of the fact if directly asked the question 
whether the bone was broken, but would frankly ad- 
mit the fact, taking care at the same time not to 
make it appear worse than the nature of the case re- 
quired, if no, or but little injury were likely to re- 
sult ; but, on the other hand, if trouble were likely 
to result from the accident, I would at once, whether 
asked or not, tell what had happened, and what re- 
sults might be expected. When the alveolus has 
been fractured, whether much or little, and there are 
any loose fragments remaining, they should be care- 
fully removed ; and if there are any sharp projecting 
points left, they should be removed with the cutting 
forceps, or some other convenient instrument ; other- 
wise they will be liable to produce irritation and in- 
flammation of the gums. 

This, in ordinary cases, is all the treatment that 
will be required ; but severer cases, if they occur, must 
be treated according to the general principles of 


I have very recently known of quite an extensive 
fracture of the alveolus, including a considerable por- 
tion of the superior maxillary bone, in the hands of 
a young operator, by the use of the elevator, — the 
kind of elevator intended for the removal of roots. 
The case, as described to me, was this. A lady of 
about thirty years old had had bad teeth for many 
years. The crowns of nearly all her upper teeth were 
gone, while the roots still remained. Some of them 
had been the cause of alveolar abscesses. The gums 
were in a very unhealthy condition from chronic in- 
flammation and tumefaction. She had determined 
to have them all removed and to have artificial ones 
inserted in their place, and went to her dentist for 
that purpose. He had, without difficulty, removed 
some of them, when, coming to the roots of the second 
right upper molar, he attempted to remove them also, 
with his elevator. To his surprise, he presently 
found that the decay had not proceeded quite far 
enough to separate the roots, and that he had, with- 
out the use of very much force, loosened them all, 
and with them a large portion of the alveolar pro- 
cesses ; but although these were loose, he could not 
remove them. Finally, with much embarrassment 
and anxiety, on both his part and his patient's, he 
dissected away the gum, on both sides, and removed 
the mass, which proved to be the roots of the tooth, 


a portion of the alveolus about half an inch in length, 
including both walls and their septa, and enough of 
that portion of the maxillary bone which forms the 
floor of the antrum maxillare to make a very distinct 
opening into that sinus. 

A few days afterward the parts thus removed 
were shown to me. On examination, it was evident 
that a considerable portion of the outer- wall of the 
alveolus had been removed by the effect of abscess, 
and necrosis had taken place in that wall and in the 
septa, and had extended nearly through a portion of 
the inner wall or plate, leaving but a very thin por- 
tion of sound bone. 

This accident, though quite formidable in appear- 
ance, and very embarrassing to so young an operator, 
was of no serious importance, and would most likely 
have occurred in the hands of any one, and by the 
use of any kind of an instrument. The wound 
healed kindly and well. 

As apropos to the foregoing case, I was once 
called on by a physician to go with him and extract 
a troublesome tooth for one of his patients, who was 
suffering from a long lingering consumption. 

TV r e found the patient in bed ; his whole mouth in 
a very bad condition. After examining the offend- 
ing tooth, I grasped it with my forceps, and with a 
very small degree of force removed, not only that 


tooth — an upper molar — but also the one next back 
of it, and the entire alveoli belonging to both. On 
examination I found the bone necrosed and about 
as brittle and friable as so much dry hemlock bark. 
This accident, the fracture of the alveolar process, 
is by patients most commonly denominated " break- 
ing of the jaw," a term that sounds quite formidable ; 
and true, fracture of the jaw really is quite a for- 
midable accident, but it is one that I have never 
known to occur in extracting or in attempting to 
extract a tooth, but in one instance. That case I 
will here relate. 

Sec 5. Fracture of the Jaw from Extracting a 
Tooth. — In the year 1845, Mr. L., living near Colum- 
bus, Ohio, sent his son, a boy of about eight years 
of age, to that city, to have his first permanent 
right lower molar tooth extracted. He went to 
some one practising there as a dentist, and submitted 
himself to the operation. What kind of an instru- 
ment was used I do not know, or in what manner 
the accident occurred — I should, perhaps, the rather 
say, how the crime was committed — I am ignorant.; 
but in extracting the tooth, the operator broke the 
jaw entirely off, just in front of the tooth extracted. 
Ei ther from not being aware that he had committed 
the injury, or from an entire ignorance of what was 



necessary to be done to retrieve it, or from want ot 
the courage to own it, he suffered the hoy to leave 
his office with the fracture unreduced, and without 
informing him or his parents of the injury that had 
been committed. 

The boy returned to his home, with his tooth out, 
to be sure, but not in a very pleasant plight, for he 
still suffered severe pain, and soon his face became 
very much swelled. This, however, was probably 
supposed to be a natural consequence of the opera- 
tion, or the result of "taking cold," and did not 
attract particular attention ; or, at most, not enough 
to induce his parents to have it professionally exam- 

About three months after the operation, the father 
removed to the vicinity of this city, where he had 
formerly lived, and then brought him to town for 

I saw him at that time, though the case was not 
in my care. Then the face was very much SAvollen, 
and there was a large fistulous opening at the place 
of the fracture, with a discharge of fetid, sanious 

The gentleman in whose charge the little patient 
was, from the great amount of swelling, and not 
mistrusting that such an injury could have been in- 
flicted, and so neglected, did not at that time dis- 


cover the extent of the injury, hut supposed it to be 
a case of very had fracture of the alveolus. He re- 
moved some loose fragments of bone, and recom- 
mended some treatment to correct the fetor of the 
discharge, and, for the rest trusted to time. He saw 
him occasionally, and directed such treatment as the 
case seemed to require. 

At the end of about three months from his first 
being brought to town, or about six from the time 
of the accident, the swelling had considerably sub- 
sided ; when, on a more critical examination, it was 
found that the jaw had not only been entirely broken 
off, but that it was now dead and loose in the flesh ! 
The broken end of it was, therefore, seized with a 
pair of forceps, where it presented at the fistulous 
opening, and, with but very slight force, was removed 
entire, from just in front of the first molar tooth 
to its free articulation. I was present, too, at this 

The wound* after this healed kindly, but the now 
unopposed contraction of the muscles on that side so 
drew around the chin as to produce great and per- 
manent deformity. 

It may be proper further to state here, that a 
somewhat remarkable, or at least unexpected, fea- 
ture of this case was, that in about six months from 
the removal of the dead bone, a new one was formed 


in its place ; but it extended in a straight line from 
the place of fracture to the articulation, without any 
angle. And what was a still more remarkable fea- 
ture in the case was, that not long after that time, 
a new tooth was found cutting from this new bone. 
Although this is an accident that but very rarely 
happens, and that ought never to happen, it is well 
to know that it may happen, because it has hap- 
pened. And if so unfortunate an occurrence should 
ever -befall any one, he should immediately reduce 
the fracture, and take the proper means to keep the 
fractured ends of the bone in perfect apposition ; or, 
if not competent to treat the case himself, he should 
at once call the aid of a competent surgeon. 

Sec. 6. Extraction of a Wrong Tooth. — This is an 
accident of not very frequent occurrence, but still 
more frequent than it should be, for it occurs not 
only sometimes unavoidably, and sometimes by mis- 
take, that may be excusable, but sometimes by sheer 
carelessness, for which there is no justification or 

Sometimes a patient applies to have a perfectly 
sound and healthy tooth taken out, saying that the 
pain in it is intolerable, and insists on having it out, 
when the seat of the pain is in a contiguous tooth, 
or even in one quite remote from it ; or, it may be, 


that the origin of the pain is in no way connected 
with the teeth. One unobservant or unacquainted 
with the pathology of toothache would, under such 
circumstances, be very likely to rely on the impres- 
sions of his patient, and to be guided by his wishes, 
and take out the tooth pointed out to him. This, 
too, would be an inexcusable error, for no one ought 
ever to pretend to extract teeth, until he can by his 
own examination, more certainly tell what tooth 
aches than can his patient. 

But sometimes, as for example, it happens that a 
molar tooth has a small but deep decay near the 
centre of one of its approximal surfaces, and where, 
from its position, neither the eye nor an instrument 
can reach to explore the cavity. In such a case we 
must mainly rely on the impressions of the patient, 
and if they are wrong, we shall be liable to take out 
the wrong tooth. This, when no care on the part of 
the operator has been omitted, is an excusable mis- 

Again, it sometimes happens that when a molar is 
to be extracted, the root of a bicuspidatus adjoining 
it may be partially imbedded in a groove in the root 
of the molar, and the roots of the molar, by being at 
the same time considerably divergent, may extend 
partially under that of the bicuspidatus, when, on 



removing the molar, the bicuspidatus is of necessity 
brought away with it. But as no amount of care 
could predetermine their relation, and no skill could 
avoid the result, the operator is not to be blamed ; 
and all that could then reasonably be asked or ex- 
pected of him would be that he make the best repa- 
ration in his power. 

This last-named accident has twice occurred in my 
own practice. In extracting a molar, whose roots 
were divergent and deeply grooved on their outer 
approximal surfaces, a bicuspidatus, whose root was 
partially imbedded in the root of the molar, was 
brought away with it, and when the instrument was 
fairly and perfectly placed on the molar, which was 
so much larger than the other tooth that the instru- 
ment did not, and could not in the least, impinge 
upon, or even touch the smaller tooth. 

In such cases, both for the satisfaction of the pa- 
tient, and to protect the reputation of the operator, 
the teeth should at once be shown to the patient, and 
the circumstances explained and illustrated. 

But when from any cause, whether justifiable or 
unjustifiable, a tooth has been taken out that ought 
not to have been, a very important question arises, 
to wit : what shall be done with it ? To this question 
different answers have been given. But, from the 
few cases that I have myself tried, a few that have 


come under my observation in the hands of others, 
and several reports of other well-attested cases, I 
could feel justified in taking, or in recommending but 
one course ; and that course would be, immediately 
to replace the tooth as nearly as possible in its origi- 
nal position, and then require the patient to close the 
jaw T s firmly, till all the other teeth come fairly in con- 
tact ; thus assuring myself that the tooth did not 
stand too prominent, and would not ultimately in- 
terfere with the perfect closing of the jaws, or in 
other words, that it was perfectly in its place. 

In almost every case, probably in every case where 
the circumstances are not particularly unfavorable, 
where this course is pursued, it will be found that in 
a few days the tooth has become re-attached by its 
periosteum to its socket, and as fully restored to use- 
fulness ; the only inconvenience experienced, having 
been some soreness ; enough, perhaps, to require the 
use of such food as would not require much mastica- 
tion for a portion of the time. I have never yet seen 
a case of the kind fail ; but it is true that the few 
cases I have seen were favorable cases. But, although 
in a generally unhealthy state of the mouth or of 
the system it might fail, and would be more likely 
to fail than under more favorable circumstances, I 
would still most strongly recommend a trial of it in 
all cases ; for, in surgery, sometimes what seem to be 


very unpromising cases, turn out even unexpectedly 

Sec. 7. Dislocation of the Lower Jaw. — In some per- 
sons with very lax muscular and ligamentous fibre, 
and, especially, if they have large mouths, this is an 
accident very easily produced. Yawning, only, some- 
times produces it, and when it has once occurred it is 
more likely to re-occur than before ; and it probably 
more frequently happens by the patient suddenly 
opening the mouth to its fullest capacity to admit of 
an operation, than by the operation itself. 

In the use of forceps, if the chin is firmly grasped 
by the left hand, as it always should be, the jaw re- 
ceives such support as to render it almost impossible 
to dislocate the jaw. In using the key, the chin 
cannot be thus seized and supported, and if the ful- 
crum of that instrument be next the tongue, as is the 
most common way of applying it, a severe strain is 
made on the articulation of the opposite side of the 
jaw, which may produce, and often has produced, 
this accident, which can only be produced by the de- 
pression of the chin, thus turning the condyle or con- 
dyles, as the luxation may happen to be of one or of 
both articulations, out of its socket, and lodging it in 
front and above the glenoid fossse with which it 
articulates. The mouth will then be opened to its 



fullest extent, the jaw fixed, and the countenance ex- 
pressive of great anxiety, as illustrated in Fig. 41. 
Fig. 41. 

From a study of the action- of the musdes which 
close the jaws, it will at once be seen that the force 
required to reduce the luxation must be directly 
downward ; and when the jaw has been forced down 
till the condyles are opposite their sockets, the mus- 
cles themselves will carry them backward, with a 
sudden snap, into their proper places. 

The necessary force to effect this object can most 
readily be applied by placing the thumbs on the pos- 
terior teeth, or if they are gone, by placing them as 
far back as may be on the jaw, using them as a ful- 
crum, while, with the fingers, the chin is forcibly 

Some recommend the use of corks or other sub- 


stances, placed between the molar teeth as fulerums, 
instead of the thumbs, but they require more display, 
are less readily managed, and are less effective. But 
when tKe thumbs are used, "it will be but a prudent 
precaution to wrap them with napkins or any other 
convenient material, lest in the sudden closure of the 
jaw they be bruised by the teeth. 

In the dislocation of the lower jaw, as in disloca- 
tion of all other joints, there must necessarily be more 
or less straining or even rupture of the capsular 
ligaments ; therefore, till the parts have had time to 
recover their strength, after such an accident, care 
must be used to avoid opening the mouth further 
than is necessary for the reception of soft food, lest 
the accident be reproduced; and to guard against 
this, it may be well to affix a bandage over the head 
and under the chin, so as to restrain the motions of 
the jaw within certain limits. 

Such bandaging, too, will be a prudent safeguard 
in preparing to extract a tooth for one in whom the 
accident is known previously to have occurred, for, 
as already remarked, when this accident has once 
occurred, it is more easily reproduced than before. 

Sec. 8. Syncope, or Fainting. — With some, syncope 
seems almost to be a habit, they being subject to it 
from the slightest causes, and almost all occasions, 
as from sudden sensations of pain or fear, sorrow or 


joy. Some are liable to it under certain conditions 
of the system, but never otherwise. There are no 
distinctive indications known to the writer, by which 
to determine who are liable to it, or under what cir- 
cumstances. Sometimes, the apparently healthy 
and strong are very liable to it, while others that 
are feeble and sickly never faint, and the reverse. 

I once saw a healthy, strong, robust and brave 
man faint entirely away, from the slight scarification 
of the arm in the operation of vaccination. 

This accident is quite as likely to occur from the 
dread of the operation, as from the operation itself. 
It sometimes occurs simply from a sight of the in- 
struments to be used, and frequently from the sight 
of blood ; therefore no unnecessary display of instru- 
ments should ever be made, and what are necessary 
should always be clean and in good order, ready for 
immediate use ; and no blood should in any way be 
drawn, if it can be avoided, until the tooth is ex- 
tracted ; and after one operation, all instruments and 
vessels should be carefully cleansed and freed from 
all stains or appearance of blood, before another is 

A rough and unfeeling manner sometimes causes 
fainting, therefore kindness and gentleness of man- 
ner, especially with female patients, should most 
sedulously be cultivated and observed. 


" It " (syncope) " consists in an intermission of the 
heart's action, and consequently irregularity of the 
circulation of the blood, accompanied with a tempo- 
rary suspension of the functions of the brain, and a 
loss of consciousness." The first indication of its 
approach, generally, is that the patient complains of 
nausea, and a ringing in the ears, accompanied with 
pallor of the countenance, and partial or complete 
prostration of muscular energy, witt irregular or 
suspended respiration. 

The readiest way of restoring a patient from syn- 
cope, is to place him in a horizontal position, free 
from all compression and restraint of the neck, chest, 
and respiratory organs ; admit a full and free supply 
of fresh air ; apply aqua ammonise or other volatile 
stimulants to the nostrils, or dash cold water in the 
face, with friction of the extremities. Or, what I 
have frequently found more effective than any other 
remedy, especially if the patient be not habituated 
to its use, is to give a teaspoonful or two of brandy 
with about an equal quantity of cold water. Much 
more than this, to one accustomed to its use, will be 

Sec. 9. Hysteria. — With those subject to this dis- 
ease, the dread or the shock of this operation is fre- 
quently sufficient to develop it. It has occurred 


several times in my own practice from the dread of 
having a tooth extracted, and a few times from alarm 
at the peculiar sensation produced by the first sensi- 
ble effects in inhaling ether ; and I have seen it from 
these canses in the hands of others. 

The symptoms are various; at different times 
simulating almost all manner of diseases. Anions: 
the most common, however, are a sense of suffocation 
or choking — the " globus hystericus " of the old 
writers — apparent syncope, and spasms or cramps of 
the muscles of the abdomen, chest, neck, and limbs, 
and especially of the hands and fingers, which are 
frequently as rigid as if they were frozen ; all accom- 
panied with a sensation of great fatigue, which they 
often express by saying, " I am so tired." This com- 
plaint occurs much more frequently with females 
than with males. 

The most effective remed}^ usually, is either some 
anodyne — the most satisfactory of which I have ever 
tried being small doses of the tincture of assafoetida 
— or entire neglect. The appearance of the patient, 
to one who has never before seen the affection, is 
often truly alarming ; but the anxiety and sympathy 
of friends or attendants almost always aggravate the 
complaint. Fortunately the prognosis is nearly 
always favorable, and time and proper neglect will 
generally at least afford relief. 




A work of this kind, at the present day, might 
seem to be incomplete without something being said 
on anaesthetics. But on this subject I have but little 
to say. 

In all serious surgical operations, and especially 
where " the shock of the operation " is liable to en- 
danger the life of the patient, the administration of 
some anaesthetic is not only justifiable, but the ne- 
glect to use it, unless seriously objected to by the 
patient or his friends, would be highly reprehensible ; 
or in cases of difficult parturition, where the pains 
and fatigues are more dangerous than the anaesthetic 
agent — and here I will remark parenthetically, that 
from the best information that I can gather on this 
subject, that patients already suffering severe pain 
are less liable to sink under the use of such agents, 
than under other circumstances — it ought not to be 
withheld. But, in the operation of extracting the 
teeth, I avoid them generally ; and, indeed, in all 
cases, unless strongly urged, and for these reasons. 


There is no serious danger from the shock of the 
operation ; at the most, I have certainly never heard 
of death resulting as the immediate effect of extract- 
ing a tooth ; and it is usually, when skilfully per- 
formed, an operation of very short duration. 

Experience has proved that there is some danger 
from the use of some of the agents used to produce 
anaesthesia. Many lives have been lost, both in this 
country and in Europe, from the effects of chloro- 
form. Sulphuric ether is disagreeable to some, very 
disagreeable to others, and to others again uncertain 
in its effects, producing only excitement without an- 
aesthesia. I would sooner endure the pain of extrac- 
tion than the discomfort of inhaling ether. 

Probably very few persons operate as carefully, 
when their patients are under the influence of an 
anaesthetic, as when not, and for two reasons. First, 
they are likely to operate hurriedly, lest the influ- 
ence of the anaesthetic pass oft' before the operation 
is completed ; and, secondly, one is not apt to feel 
the same amount of responsibility and need of care 
when he knows his patient feels no pain, as under 
other circumstances ; therefore accidents are more 
apt to occur with the use of these agents than with- 
out them. 

Within the last few years various substances and 
appliances have been recommended, for the purpose 


of producing " local anaesthesia." The most promi- 
nent of these are : chloroform, applied directly to the 
part ; various freezing mixtures, similarly applied ; 
and electricity. But for my own observation, and 
the best information I can obtain, they are not en- 
titled to any serious consideration. 

The smarting from the application of the chloro- 
form is quite as severe as the pain of extraction, 
and is, therefore, at best, but a change of disagree- 
able sensations, a kind of translation of pains ; if, in- 
deed, it at all relieves the pain, and is not rather a 
smart, superadded to the pain. 

The freezing mixtures are totally inadmissible in 
most cases, or except where the tooth to be extracted 
stands isolated from the rest, and they are always 
liable to produce severe injury, and even sloughing 
of the gums and surrounding parts.* 

Electricity, in many cases where its use would be 
most desirable, only intensifies the pain ; and in all 
the rest, probably only diverts the attention, by pro- 

* I have quite recently been shown, by a dentist of Pittsburg, 
Pa., a part of an apparatus for conveying cold to a tooth, so as to 
prevent the sense of pain during extraction ; which was represented 
to me as producing the effect most perfectly, and without any 
danger of accident from its use. But the apparatus being, as was 
alleged, about to be patented, and the holder being under bonds 
not to exhibit it till the patent was secured, of course I could not 
be favored with an exhibition. 


ducing a different kind of pain from that of the op- 
eration to be performed. 

Of all the agents nsed for producing insensibility 
to pain, at present known, chloroform and ether are 
probably the only two to be relied on,* and these 

* Since the publication of the first edition of this work, the 
use of protoxide of nitrogen or nitrous oxide has been revived as 
an anaesthetic, and has come into very general use. (It will be 
remembered, by those familiar with the history of anaesthesia, 
that Dr. Wells at first used the nitrous oxide for this purpose.) If 
the gas be pure, and properly administered, the results, to oper- 
ators and patients, are very satisfactory. Without these precau- 
tions, dangers may be apprehended. 

There are two methods in common use of administering it. One, 
and, as I think, the only true one, is by means of a double-valved 
mouthpiece, so contrived that the exhalations are thrown oflf, and 
not returned to the receiver. The other is by the use of an India- 
rubber bag, with a mouthpiece without valves ; the exhalations 
being returned to the bag to be rebreathed. When this method 
is adopted, care should be taken that the bag be large — of the 
capacity of at least six gallons — or there will be danger of asphyxia 
from the inhalation of carbonic acid gas. 

My attention was especially called to this danger in my own 
person, when I first commenced the use of this article ; I was tak- 
ing it then, to exhibit its effect. Not thinking of this danger, 
and not wishing to render myself very insensible, I took not 
more than three gallons, or less, in the bag. I very soon became 
insensible, and on returning to consciousness was told by the by- 
standers that my face became livid, and that I was convulsed, 
and clutched the bag so strongly that it required some force to 
remove it from my grasp. I immediately reasoned, that, as it is 
oxygen that gives the florid color to the blood, while carbonic 
acid gas turns it dark, it was from the effect of the carbonic acid 
gas that I had been made insensible. 

Of its safety, with due observance of these cautions, I have no 


only by producing general anaesthesia ; and of these 
two, from its milder action and greater safety — 

doubt, as it has now been very extensively, and not always over- 
carefully, used, with but very few, if any, well-authenticated ac- 
cidents having occurred. At one time I, myself, took it four times 
a day for six consecutive weeks ; genera lty almost, and sometimes 
quite, to the point of insensibility; and with no other apparent 
effect than the naturally to have been expected one, of a slight 
diminution in flesh. As ^ curative agent it did not realize my 

The advantages of nitrous oxide over other general anesthetics 
now in use, are, that it has no unpleasant taste or smell, the som- 
nolent state is quickly induced, without any stage of excitement, 
and then passes off quickly, so quickly that in the space of two or 
three minutes at most, all sensible effects either to bystanders or 
patient will be gone. 

The principal disadvantages attending its use, are the greater 
expense and trouble of manufacturing it, and especially in small 
towns and villages where the demand is necessarily small. The 
short duration of its effects are sometimes an inconvenience to the 
dentist, as he cannot be operating while his patient is still inhal- 
ing the gas, as the general surgeon frequently can. 

Another new method of producing local anesthesia for extract- 
ing teeth, and performing other minor surgical operations with- 
out pain, has lately been introduced to the profession. This con- 
sists in passing a fine jet of ether upon the tooth, or other part to 
be operated upon, The ether is thrown into a fine spray, before 
reaching the part to be acted on, by means of a jet of atmospheric 
air. This causes so rapid evaporation as to proiuce freezing in a 
marvellously short space of time. With a newly discovered ether 
called Khigoline this effect may be produced in from five to ten 
seconds, while with sulphuric ether nearly as many minutes will 
be required. 

This invention has been received with considerable favor. 
Many operators speak highly in its praise. 

The objections to its use seem to be that in the posterior part of 


nearly if not quite all the lives that have been lost 
by them in this country, at least, having been from 
chloroform — I greatly prefer ether ; though, what in 
some cases is better, and perhaps as good in all, is a 
mixture of the two, in about the proportion of four 
parts of ether to one part of chloroform. 

The most convenient, and probably the safest way 
of administering either of them, is by saturating a 
napkin or a concave sponge with the material and 
holding it before the face, but not so closely at first 
as to exclude the free admission of atmospheric air 
from the lungs ; meantime closely watching the effect, 
and if no untoward circumstances transpire, after- 
ward bringing it closer and administering it more 
freely, but at no time entirely excluding the air ; and 
so continue to administer it till the desired state of 
insensibility is produced. 

If at any stage of the administration the patient 
begin sensibly to sink, as indicated by any material 
.diminution, in either the force or frequency of the 
pulse, or of pallor of the countenance, the adminis- 
tration should immediately cease and restoratives be 
resorted to.* Of these, I have seen cold douches to 

the mouth its application is somewhat difficult. An unusual flow 
of saliva also impedes the freezing- process. 

Care should, no doubt, he taken not to carry the freezing pro- 
cess too far, lest sloughing be induced. 

* These remarks will apply to the use of nitrous oxide and all 
other anaesthetics. 


the head, volatile stimulants applied to the nose, and 
if the patient be not past the ability to swallow, a 
few drachms of brandy act very efficiently in re- 
storing sensibility. In more urgent cases, electri- 
city, insufflation, or other means of artificial respira- 
tion should be resorted to, and without delay. But 
with pure sulphuric ether, and with due care in its 
administration, very little danger need ever be ap- 

I must here digress enough to say that in my un- 
prejudiced opinion, formed from all the testimony 
that has been offered on the subject, the credit of 
introducing anaesthetics for the prevention of pain 
in surgical operations is justly due to the late Dr. 
Horace Wells, of Connecticut. 

Before dismissing this subject, I cannot too strong- 
ly caution every one who administers either chloro- 
form or ether, or any other general anaesthetic, and 
whether separately or mixed, against ever adminis- 
tering it to any female patient, except in the pres- 
ence of some reliable third person. And, although, 
from my own knowledge and observation, I could 
offer reasons to enforce the necessity of this caution, 
the records of some of our courts of justice afford 
sufficient proof of its necessity without further ar- 




Abscess, alveolar, always commences at point of root, . 63 

Accidents attending the extraction of teeth, 

. 145 

breaking tooth, 

. 156 

excessive hemorrhage, . 

. 145 

fracture of alveolus, 

. 163 

jaw, . 

. 169 

dislocation of jaw, . 

. 176 

extracting the wrong tooth, 

. 172 

laceration of the gums, . 

. 161 

fainting, .... 

. 178 

hysteria, .... 


Acids, agents that produce caries of teeth, . 


Alveolar processes, lower, ..... 


upper, .... 




Anatomy best acquired in dissecting-room, . 


foundation of all surgery, 


knowledge of, indispensable in extracting 

y teet 



of jaws, 


of the teeth, 







Antrum maxillare, 

. 17 

Anxiety, undue, ....... 

. 122 

Application of forceps to teeth (general), 

. 125 

in lower jaw, . 

. 132 

(left side), . 

133, 134 

Articulation of the teeth, 

. 44 

Astringents, ........ 

. 147 

Attachment of gums to teeth, slight, . 

. 142 


Bicuspidati, upper, description of, .... 

application of forceps to, 
more liable to break than other teeth, 
Bicuspid forceps, upper, 
Bone, upper jaw, . 

form of, 
faces of, 
processes of 
lower jaw, 

rami of, 
processes of, 
Breaking of teeth, . 
Breaking of jaw, . 

















Calmness, importance of, 
Canine fossa, . 






Caries, agents that produce, . . . . . .. .47 

its causes, ..... 

. 46 

most common causes of toothache, 

. 50 

Case of fracture of alveolus, . 

. 166 

jaw, .... 

. 169 

excessive hemorrhage, 

. 151 

inflammation of dentine, 

. 67 

reproduction of dentine, 

. 71 

Causes of toothache, .... 

. 50 

Cautery, actual, 

. 147 

Central incisors, description of, 

. 32 

Children, treatment of, . 

. 123 

not to be deceived, . 

. 123 



ether, &c, not to be administered to females 

except in the presence of third persons, 


Color of teeth varies in individuals and at d 

liferent ages, 


Condyle of lower jaw, .... 


Contents, table of, . 


Coronoid process, . 


Cuspidati (upper), description of, . 


(lower), " 


forceps for, 


Cells, packing of, . 


Cobweb, .... 


Compound screw forceps, 


Compress, ..... 


Conical screw, .... 


Death from lancing gums, 




Defective knowledge of anatomy cause of failure i 

n extract- 

ing teeth, 

. 13 

Density of teeth variable, 


Dentine, susceptibility of inflammation, 


inflammation of (case), . 


reproduction of (case), 


Description of incisors (upper), . 



. 39 

cuspidati, (upper), 

. 34 


. 40 

Description of bicuspidati (upper), 

. 35 



molars (upper), 

. 37 



Diathesis, hemorrhagic, .... 


Difficulties in extracting teeth, 

. 141 

Dislocation of jaw, 

. 176 


Efforts at extracting teeth should be deliberate, . . . 126 

Elevator, straight, 117 

crooked, ......... 118 

not to be used in extracting upper wisdom teeth, . 131 
most appropriate instrument for extracting lower 

wisdom teeth, 136 

Epidemic toothache, ........ 64 

Ether, 182 

Excessive hemorrhage (case), 151 

Extracting teeth formerly consigned to barbers, ... 14 




Facial surface of upper jaw bone, 
Fainting, .... 
Fistulous discharge, 
Foramen, alveolar, 

inferior dental, 
Forceps, application of to teeth, 
compound screw, 
straight, . 
for cuspidati, . 

bicuspidati (upper), 

bad style (upper), 
(lower), . 
(lower), for excising 
molar (upper), . 
(lower), . 
lower root, 
Parmly, .... 
for deciduous teeth, . 
Koberts's (upper wisdom), 
for extracting broken teeth 

inconvenient of application to 
Form of upper jaw bone, 
Fossa canine, 
Fracture of alveolus, 

jaw bone (case), 
Freezing mixtures, 
Frequency of operation of extraction, 




lower wi 


























Gornphosis articulation, ..... 

. 44 


. 120 

Gums, attachment of to the teeth, slight, 

. 142 

lancing of, ...... 

. 139 

cause of great dread, . 

. 142 

increases danger of bleeding, 

. 143 

produces needless pain, 

. 142 

unnecessary, .... 

. 142 

argument in favor of, . 

. 143 

laceration of, ..... . 

. 161 


Hemorrhage, excessive (case), 151 

Hemorrhagic diathesis, ....... 146 

Hooks, 99 

Hysteria, 180 

Imperfect organization cause of decay of teeth, 
Importance of self-possession in extracting teeth, 
Incisors, upper (central), .... 
(lateral), .... 


Inflammation of dentine (case), . 
Instruments for extracting teeth, 

should be made of best 

Introductory remarks, 














Iron, perchloride of, 
persulphate of, 



Jaw (upper), 

. 17 


. 21 

rami of, 

. 23 

fracture of (case), 

. 169 

dislocation of, . . . 

. 176 


Knowledge of anatomy indispensable in extracting teeth, 



Laceration of gums, 


Lancing gums, 


description of operation, 


generally should be omitted, 


sometimes necessary, 


argument in favor of, . 


Lateral incisors, description of, . 


Lesions attending wisdom teeth, . 


Lower incisors, ...... 

. 39 

cuspidati, ...... 

. 40 


. 40 

molars, ...... 

. 41 

jaw bone, 

. 21 

wisdom tooth always curved, 

. 43 







Mechanical violence cause of caries, .... 


Medicines generally supposed to cause decay of teeth, 


when properly exhibited protect the teeth, 


Molar teeth (upper), 


two pairs of forceps required for, . 


application of forceps to, 




Muscle, masseter, 


pterygoid (external), .... 


(internal), .... 


temporal, ....... 


Muscles of the jaws, 

. 25 


Nasal surface of upper jaw bone, 


Nerve, superior maxillary, . 

. . . , . 17 

inferior dental, . 

. . . .21 

Nitrate of silver, . 


Nitrous oxide, 


Notch, sigmoid, 


Number of teeth in set, 


Nut-galls, .... 



Operation of extracting teeth, dread of, 

frequency of, 




Orbital surface of jaw bone, 19 

Organization, imperfect, of teeth, cause of decay, . . 49 
Oxide, nitrous, 185 

Packing cells, 

Patients often mistake in regard to tooth that aches 



Position of patient and operator in extracting teeth, 

in using elevator to extract 
lower wisdom teeth 


Pregnancy, expediency of extracting teeth during, 
Processes of lower jaw bone, alveolar, 


upper jaw bone, 









Kami of lower jaw bone, 
Remarks, introductory, 
Eoberts's forceps, . 
Robertson's forceps, 

21, 23 
. 13 
. 130 
. 113 



Boots of lower wisdom teeth always curved, 
Kules to guide in extracting teeth, 




Saliva, normal alkaline, 
abnormal acid, . 
Screw, conical, 
'Self-possession, how attained, 
importance of, 
Sigmoid notch, 
Silver, nitrate of, . 
Strength of teeth vary, . 
Symphysis of lower jaw, 













Tartar sometimes causes inflammation and pain, ... 84 

Teeth endowed with vitality, 71 

powers of nutrition, .... 71 

recuperation and reproduction, 71 
having convergent and divergent roots, require great 
force to extract them, . . . . . .132 

in lower jaw do not admit of rotary motion in extract- 
ing, 134 

temporary, ......... 29 

number of, 29 

permanent divided into four classes, .... 30 

vary in form according to configuration of persons, . 30 



Teeth, their color varies in different persons and at different 

ages, . 



density, strength, and durability, 


crowns of, 


necks of, ... 


roots of, ... 


lower incisors, descriptions of, 


cuspidati, . 






upper incisors, 


cuspidati, . 






wisdom more irregular than any other class, 


Tooth should always be examined before extracting, . 


Toothache, varieties of, and their causes, 


from exposure of nerve, 








inflammation of nerve, 












how occurs, 

V 64 





dentine, . . 


sympathy, . 





Toothache from sympathy, causes, 

case in illustration, 

diagnosis difficult, 

Trepanning tooth, .... 

Turnkey, ...... 

Turpentine, oil of, .... 


. 73 

. 74 

. 75 

. 76 
77, 80 

. 60 

. 93 

. 147 


Undue anxiety, 122 

Universality of operation of extracting teeth, . . .13 
Upper jaw, description of, 17 

Violence, mechanical, cause of decay of teeth, 
Varieties of toothache, 



Wells, Dr. Horace, 188 

Wisdom teeth, upper, 39 

lower, 42 

lesions attending their coming, ... 82 

in upper jaw, kind of forceps to be used on, 130 

Wrong tooth, extraction of, 172